Make sure you filled-out our Online Order Form before you fax this form to us
If you are making payment by check you can mail the first 3 months plus the setup charge to:

Sentris Network LLC
19662 Aurora Ave N
Seattle WA 98133

U.S. customers may also Fax a signed check to us for immediate processing, just fill out the authorization form below.

For credit card payments, please print and fax the following form to our office ASAP.
If fax is not available please send by postal mail or email to the above address or contact us for alternative way to get the form to us. Credit card accounts will be setup within 6-48 hours after we received the payment and confirmed the order and/or a copy of this form.

Fax Numbers: 1-206-577-4763 or 1-877-434-6950 (Toll Free) 

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                  ------======== SENTRIS =========-----
           Sentris Network LLC Charge and Fax Check  Authorization

CHECK OR CREDIT CARD HOLDERS 

NAME: _________________________  E-mail: _________________
ADDRESS:  _____________________  Phone: __________________
CITY: _________________________  STATE: __________________
ZIP: __________________________  COUNTRY: ________________
CC# ______________________________________________________
EXP. DATE: ____________________

Domain Name/Product/Service: __________________   

Account Type: ____________________________________ 

Authorized Monthly/Semi-Annually/Annually Charge _________________

[  ] Check
     [  ]  This Authorization is valid for this transaction Only.
           (3 months Plus setup)  
     [  ]  This Authorization is valid for my monthly/semi-annually/annually 
           payments and May be processed providing that a notice is sent that the 
           draft has been issued. (Monthly/Semi-Annually/Annually + setup)
[  ] Charge Card MC/VISA/Discover/Amex

I authorize Sentris Network LLC to deduct my normal monthly/semi-annually/annually 
service as outlined in the order form for the above domain, plus any other 
fees (see policies.sentris.com), like extra bandwidth usage. And I also 
understand that all setup and/or last-month fees are non-refundable and I've 
read and agreed to the policies stated at http://policies.sentris.com.


Signature: ______________________________________________
Paste Check On top of form