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PAYMENT AUTHORIZATION FAX FORM

Payment Authorization:

I have read and hereby agree to the terms of the Res-Q Automated Backup service agreement and;
I authorize you to charge my Visa / Mastercard (circle one) monthly for:

[  ]  US $29.95 plus applicable taxes for the Professional Edition service (C)

[  ]  Cdn $44.95 plus applicable taxes for the Professional Edition service (C)

[  ]  US $12.95 plus applicable taxes for the Personal Edition service (D)

[  ]  Cdn $19.95 plus applicable taxes for the Personal Edition service (D)

and/or annually for:

[  ]  US $39.95 plus applicable taxes for the Client Edition service

[  ]  Cdn $59.95 plus applicable taxes for the Client Edition service

Name: ________________________________ Address: ________________________________

City: ___________________ State/Prov: ___________ Zip/Postal Code: _______________

Telephone: __________________ Email: _________________________________

Product Keycode: _______________________________________________

Visa / Mastercard # __________________________ , Expiry date _________

Name on card if different from above: _________________________________

Cardholder Signature: _____________________________________________

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Print and fax this completed form to (250) 752-4550