Fax: 1-416-849-0441
Registration for a GTAstore
Client Information
Company Name:
_________________________________________________________
Web Address:
_________________________________________________________
Street:
_________________________________________________________
City:
_________________________________________________________
Province/State:
_________________________________________________________
Postal/Zip Code:
_________________________________________________________
Office Phone Number:
_________________________________________________________
Office Fax Number:
_________________________________________________________
Contact Person:
_________________________________________________________
Contact Phone Number:
_________________________________________________________
Cell Phone Number:
_________________________________________________________
Package Details
Limited Time
Promotional Offer:
Package A: set-up fee $99.00 + monthly hosting $15.00
Package B: set-up fee $149.00 + monthly hosting $12.00
Package C: set-up fee $199.00 + monthly hosting $10.00
Full amount is due annually at start of period
Money Back Guarantee if not satisfied within 10 days of purchase
Hosting can be cancel at any time, fee of remaining months will be refunded.
Payment Information
Payment Type:
Visa
MasterCard
American Express
Paypal
Money Order
Cheque
Cash
Others _______________
* Invoice will be sent by postal mail.
Card Number:
___________________________
Card Expiration:
____/______
(MM/YYYY)
3 or 4 Digit Code at Back of Card:
_______________
Name Exactly as it Appears on Card:
_________________________
Card Holder Address:
___________________________
City:
___________________________
State/Province:
__________________________
Postal/Zip Code:
_____________________
Country:
_______________________
Phone:
_________________________
Email Address:
__________________
Amount Charged To Credit Card:
$________
Signature of Card Holder:
_____________________________
Signature:___________________________/ Date:____________
(MM/DD/YYYY)
GTAstore.com
Tel: 1-416-333-3266 Fax: 1-416-849-0441
Email: info@gtastore.com - Website: http://www.GTAstore.com