Payment Authorization Form

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Testimonials

"Thank you so very much for an outstanding website! You are very professional, excellent customer service and quick design, I would recommend your services to anyone who wants a very professional website. Once again thank you so very much for every thing you've done for our company. Your company goes far beyond the call of duty when customizing your website. Reasonable, exceptional service, courteous and very helpful, awesome design."

- Todd and Tina Atkinson (www.headstonesgenealogy.com)

Electronic Check / Credit Card Authorization 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 your card or check will not be processed on this site. This is only an authorization form. Any charges may appear as Paytech Systems, Inc. on your statement.

1)   Hosting and support is $25/month once the site is completed. $25/mo. includes 20,000 page loads per month on a clustered server environment.
2)   Video hosting option is additional $25/month since videos will be stored on a separate server from the website.
3)   Texas residents are subject to sales tax.

Website

Client Name (*)

E-mail (*)

After selecting a method of payment, you'll see a button on the next page which opens up a secure page.

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. (*)

Your recorded ip is 38.107.191.118.

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