Allow 5 Days For Your Account To Be Processed & Setup
| Name: | |
| Address: | |
| Phone Number: | |
| E-mail: | |
| Billing Address (If Different from Above): | |
| Type of | Monthly Account: |
| Charge My: | |
| Account Number: | |
| Exp. Date: | |
| Security Code | [Back of Credit Card] |
| Authorized Signature: | |
| Customer Authorization and Release: I understand that my orders will be automatically charged to my VISA/MC/Discover/American Express account each month. A copy of all charges will be attached to each order for my reference. I certify that the enclosed information is true and complete. I agree to pay my charges in full within 21 days of the statement date. If an action for collection is filed, I agree to pay all costs and attorney fees incurred. | |