Credit Card Authorization Form

Name *

E-Mail *

Phone Number *

Credit Card Number *

Expiration Date *

CVV *

Type of Card *VisaMastercardDiscoverAmex

Address *

Recurring Payment? *YesNo

The Undersigned hereby declares that the credit card information listed above is true, accurate and appears in the name as stated and authorization is hereby given to the above named individual to use this card for services rendered. Furthermore, I authorize my Credit Card company to accept and to charge to my account for services rendered initiated by the above named individual*

Todays Date *

Terms and Conditions* - I accept the terms and conditions stated above

5 + 1 = ?Please prove that you are human by solving the equation *