BizPlus Account Application Fax Form

Account Application Fax Form
Please print out the form below and submit it to BizPlus via fax at (704) 660-9817. If you are paying by company check, please enclose this form and your remittance in an envelope addressed to: BizPlus, Inc., Attn: New Accounts, P.O. Box 29326, Charlotte, NC 28229-9326.

Company:

First Name:

Last Name:

E-Mail Address:

Address 1:

Address 2:

City:

State:

ZIP:

Country:

Phone:

Account Type (Select One):
_______ Basic
_______ Professional
_______ Prestige
_______ Elite

Payment Type (Select One):
_______ American Express
_______ Discover
_______ MasterCard
_______ Novus
_______ Visa
_______ Check (Read Below)

Card Number:

Expiration Date:

* - If paying by check, please include check number and date in "Card Number" and "Expiration Date" fields respectively.

Checks are accepted in six (6) month, non-refundable payments only. Initial check must include any applicable start-up and/or InterNIC fees in addition to first six months' BizPlus charges as identified in our price listing at http://www.bizplus.com/zhosting/prices.html. Accounts will then be activated upon receipt and successful deposit of check. Client will then be notified through electronic mail at the supplied address.