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Please print out this section to provide a signature, acknowledging the full
completion of the sign up process, Terms and Agreements found at the below URL:
( http://midphase.com/tos-aup.shtml ) 
as well as the receipt of your username and password from midPhase Services, 
Inc. 

PLEASE PRINT CLEARLY!

	Name..........[_____________________________________]

	Domain........[_____________________________________]

	Phone Call ID.[_____________________________________]

	Hosting Plan..[_____________________________________]

	Card Num......[_____________________________________]

	Signature.....[_____________________________________]

I hereby acknowledge receipt of services and agree to pay any and all fees 
to midPhase Services, Inc. as stated in my	Card Holder Agreement from my 
credit card company and in midPhase Services, Inc. Terms of Service Contract, 
to which I agree fully and unconditionally. 

Please include in the below white space a photocopy or a pencil scratch of 
the credit card used in this transaction. If we do not receive this form
within 7 days (including weekends and holidays) of the date your account
was opened, we reserve the right to close your account until such form is
received by midPhase Services, Inc. Use space below for card scratch.

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