|
| *Credit Card Type |
Visa
MasterCard
American Express
|
*I hereby authorize a one time
charge to my credit card for
|
|
| *Credit Card Number |
|
| *Name as appears on Credit Card |
|
| *Credit Card Expiration Date |
|
|
|
|
Credit Card Mailing Address
if different from above |
|
Some credit card companies also request the 3-digit number that appears on the
signature space on the back of the credit card.
|
| *Number on Back of Credit Card |
|
|
| *Please find enclosed our check in the amount of US$
|
| *Date |
|
| Signature |
|
