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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.