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HOSTING & SUPPORT AGREEMENT FORM 
 
Please fill out the form below. Any sensitive information will be encrypted in our database. We currently do not accept AMEX or Discover. Please note that you'll not be charged from this website. This is only an authorization form. 
Website
Client Name: (*)
Address (card holder)
City
State
Zip
Phone
E-mail (*)
After selecting a method of payment, you'll need to fill out the applicable fields on the next page.
Transaction Amount (*)
$25 per month as auto debit
$250 for the year paid at once (save 17%)
Method of Payment
ACH or Electronic Check (checking account)
ACH or Electronic Check (savings account)
Credit Card (Visa)
Credit Card (Master Card)
I authorize Paytech Systems, Inc. to debit (credit if necessary) my bank account using ACH or debit my credit card automatically on behalf of the company named above for purposes of collection and distribution. The information I have provided to the company and Paytech Systems, Inc. is true and correct to the best of my knowledge. I further certify that the bank account I will be using fully complies with the provisions of U.S. law. I acknowledge that there will be a $25.00 penalty for each returned check due to insufficient funds and Paytech Systems, Inc. has my
authority to debit my bank account electronically. I also agree to the terms and conditions above.

1. If the entire year’s amount is paid, refund will be calculated using the regular monthly fee of $25.

2. $25 per month covers 20,000 page loads not including the site owner’s.

3. Additional page views will be $25 per 10,000.

4. There will be 8.25% added to Texas residents. (*)


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