Web Hosting Service Form

1. Just print out a hard copy of this form.
2. Fill out form completly
3. Fax back to (718) 236-8338, or mail to:

Skywiz Internet Services
7400-20 Ave.
Brooklyn, New York 11204

Customer Information(Bill to):

Name/Contact:_______________________________________________________

Company/Dept:_______________________________________________________

Address:____________________________________________________________

City:_________________State__________Zip___________Email____________

Home phone___________________Business phone_____________Fax_________

Payment Information

Method of payment:_____Credit card_____Check_____Cash_____Money order

Name on credit card_______________________Billing Address________________

Account number_________________________Expiration date_________________

Signature________________________________________date_______________

This agreement between Skywiz Internet Services and_____________________________ is for a period of 12 months at a rate of only 9.95 per month.

one time setup=9.95
9.95 X 12= 100.70
Total=110.65