Credit Application

Please fill out this credit application for your payment plan you agreed to with

Premier Hosting Company

Please mail it to:

Premier Hosting Company

2700 West College Ave. 9-349

Appleton, WI 54914

Company Name: _______________________________________________

Domain Name: ________________________________________________

Applicants Name: ______________________________________________

SSN#: _________-_________-_________

DOB: _____________________________

Street Address: ________________________________________________

City/State/Zip: _________________________________________________

Time At Current Address: ___________________

Telephone: _______________________________

Fax: _____________________________________

Email: _______________________________________________________

Bank References:

Bank Name: ___________________________________________________

Name on Account: ______________________________________________

Phone #: ____________________________________

Account #: ___________________________________

Address: ______________________________________________________

City/State/Zip: _________________________________________________

Employment References:

Employer: ____________________________________________________

Supervisor: ___________________________________________________

Phone #: ______________________________________________________

Address: ______________________________________________________

City/State/Zip: _________________________________________________

Terms:

1) In the event of default in payment, if the account is placed with an attorney or collection

agency, applicant agrees to pay all the expenses and costs of collection to include reasonable

attorneys fees.

2) This agreement shall be governed by the laws of the State of Wisconsin and applicant consents

to the jurisdiction of the court of the State of Wisconsin for Winnebago County or any federal

district court having jurisdiction therein for the determination of all disputes arising under this

agreement.

3) Applicant authorizes Premier Hosting Company or any credit bureau or other investigative

agency employed by Premier Hosting Company to investigate the references listed herein for

verification and to thereafter obtain, from time to time, credit reports to evaluate its

creditworthiness.

Print Name: ___________________________________________________

Signature: ____________________________________________________

Date: ___________________________