Credit Card Form Authorization - Extreme Vision Now

Please provide us with the Credit Authorization

Credit Card Form

Company's Name *

Contact Name *

Name on Card *

Credit Card Number *

Month *

Year *

CVV *

Billing Address *

Billing Address

City

State/Province

Zip/Postal

Country

Credit Card Authorization

The undersigned authorizes and requests Extreme Vision Now to charge the above credit card on a recurring basis for the amounts owed as agreed in client agreement. After the agreed initial term, this agreement will be a month to month agreement and can be cancelled with a 30-day written notice. Should charges be declined, Extreme Vision Now, will promptly re-charge the card for the amount due. A late fee of 5% will be applied after 5 days past due.

Signature *

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Signature