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OUT OF STATE SERVER REGISTRATION

Please complete the order form below to register your company.

* indicates required fields

* State:
* Company Name:
* Company Phone:
Company Website:
* Billing First Name:
* Billing Last Name:
* Billing Address:
* Billing City:
* Billing State:
* Billing Zip Code:
Monthly Subscription:
* Authorized By:
* Card/Account Holder's Name:
*Last 4 Digits of Credit Card/Account
(you will be contacted by phone for complete credit card number)

SECURITY VERIFICATION: Please insert the correct answer in the box*:
6 + 3 =


By my Digital Signature below, I hereby Authorize all charges associated with the above services requested by me, the card holder, paid to: James Thomas / ServesRus.com c/o Authorize.net

* Digital Signature Authorizing Charges: /s/

Thank you for your registration, you will be contacted by phone (for security purposes) for complete Credit Card information. You will be charged on the 1st of each month by Authorize.net and can cancel your subscription at any time via email notification. Please call with any questions.



Registered: 2015-41 | Bonded: 14724713 | Licensed: N7746384 | Insured: 28344

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