CREDIT CARD AUTHORIZATIONCredit Card Authorization Agreement • February 3rd, 2015
Contract Type FiledFebruary 3rd, 2015Billing Address: City: State: Zip: Indicated Card type: ർ VISA ർ Master Card ർ Discover ർ American Express Indicated Card Number: Name On Indicated Card: Expiration Date of Indicated Card (mm/yy): Backup payment method: ർ VISA ർ Master Card ർ Discover ർ American Express Number of Card to be Charged Subsequently Name On Card to be Charged Subsequently: Expiration Date of the Card Charged Subsequently (mm/yy):