CREDIT CARD
AUTHORIZATION FORM (please type or print)

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COMPANY INFORMATION (please print all information in this section):

Legal name of business or individual authorizing this charge transaction:_______________________________________________

Physical Address:__________________________________________________________________________________________

City, State or Province, Postal Code:____________________________________________________________________________

Business Phone and Fax:____________________________________________________________________________________

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CREDIT CARD INFORMATION (please print all information in this section):

Credit Card Type (check one): __VISA, __MASTERCARD, __AMERICAN EXPRESS, __DISCOVER

Credit Card Number: _____________________________________________________________ Expiration Date: _____________

Last 7 numbers located on the back of the card, on the signature stripe): _____ _____ _____ _____ _____ _____ _____

All personal or business names, precisely as they appear imprinted on the card:
1.____________________________________________ , 2.____________________________________________

Authorized Amount To Charge To Card:__________________________

Complete mailing address where your credit card billing is sent:____________________________________________________

City, State or Province, Postal Code: _________________________________________________________________________

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IMPORTANT:

The undersigned hereby declares that the credit information listed above is true, accurate and appears in the name as stated and authorization is hereby given to the above named individuals to use these cards for services from Website Advancement. Further, I authorize my credit card company to accept and to charge to my account for services initiated by the above named individuals. This authorization allows Website Advancement to continue to use this information and such information shall remain in full force and affect for the sole purpose of maintaining services specified within the services agreement unless I revoke such authorization in writing.

Authorized Cardholder Signature X___________________________________________________ Date:_____________________

Under no circumstances will this information be given out to any individuals or companies outside of Website Advancement.