EmailMe Form - Credit Card Authorization

Name *
First Last
Phone *
### - ### - ####
Email
Billing Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Credit Card *

Card Number

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Signature
Clear
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described, and for any and all overages that may incur and or any additional services ordered, this authorization is for use for my account only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
Date
MM / DD / YYYY