Quantum Internet Systems Payment Authorization Form

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.

Website (If Applicable)

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 (*)

Credit Card (Visa)
Credit Card (Master Card)

I authorize Quantum Internet Systems, Inc. to debit my credit or debit card automatically on behalf of the company named above for purposes of collection and distribution. The information I have provided to the company is true and correct to the best of my knowledge. I also agree to the terms and conditions of Quantum Internet Systems, Inc. (*)

Your recorded ip is 216.73.216.246.

(*) is a required field.

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Terms and Conditions

Quantum Internet Systems, Inc.