Circle one: VISA. MASTERCARD. AMERICAN EXPRESS. DISCOVER. 3-Digit Security Code: ___ ___ ___. AMEX 4-Digit Security Code
Credit Card Authorization Attn: Compliance Department
Client Email Address: _________________________________________________________________________
Credit Card Number:
___ ___ ___ ___
___ ___ ___ ___
Circle one: VISA MASTERCARD 3-Digit Security Code: ___ ___ ___ Billing Zip Code: ______________ Expiration Date: ___ ___ ___ ___
___ ___ ___ ___
___ ___ ___ ___
AMERICAN EXPRESS AMEX 4-Digit Security Code:
DISCOVER __ __ __ __
I authorize my credit card to be billed the full amount, as listed in the agreement. $____________
NOTICE: All Credit Card charges are Nonrefundable
X _____________________________________
Name of Individual as name appears on the Credit Card: X____________________________________________________________________________________ _ Signature: X __________________________________Print Name: X ___________________________________ Billing Address: _____________________________________________________________________________________ City, State, and Zip: ____________________________________________________________________________ Contact Phone: __________________________________Today’s Date: ______________________________
Please Complete This Form and EMAIL to:
[email protected] or Fax to: (877) 202-9065 For office use only: Charge Processed
Approval # __________________ References # __________________ Batch # __________________
Authorization Only Approval # ___________ References# ___________ Batch # ___________
