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CREDIT CARD CHARGE FORM
CREDIT CARD CHARGE FORM
Please fax
this form to 615-250-0530
Type of
Credit Card: American Express □ Discover □ MasterCard □ Visa □
Credit
Card Number: ________________________________________
CVV Security Code (usually 3 or 4 digits on back of card): __________
Expiration
Date: ___________________________________________
Name on
Card: ____________________________________________
Cardholder's
Billing Address: _______________________________________
City:
_____________________ State: _________ Zip Code: ________
Phone:
___________________________________________________
Signature
of Cardholder: _____________________________________
Service(s) Ordered
(Airfare, VIP Service, Cell Phone, etc.)
______________________________________
Total Amount
Charged (USD): $__________
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