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AUTHORIZATION TO CHARGE
CREDIT CARD
Version:101
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User ID: |
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Office Use Only |
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Company Name: |
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please fill in |
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Email Address: |
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please fill in |
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Name On Card: |
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please fill in |
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Credit Provider: |
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please fill in |
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Credit Card Number: |
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please fill in |
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Expiration Date: |
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please fill in |
I authorize Bolton E. Trading Ltd to debit my credit card as a monthly recurring
charge for services rendered at agreed published prices. Any charges made to the
credit card above under this agreement will constitute in effect a "sales
receipt"; and that services were rendered and received. Should I dispute a
charge through my credit provider this will constitute a breach of this
agreement and will result in immediate deactivation of all current services.
I have included a
legible photocopy of the credit card both front and back and have signed the
photocopy.
Signature
______________________________________
Date ________________
- INSTRUCTIONS:
- Please do the
following:
- Print, sign, date
then fax to Bolton E. Trading Ltd
- Fax:++35725359262
- Please mail by post
the original to Bolton E. Trading Ltd
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- Bolton E. Trading
Ltd
- 199 Arch Makarios
III Avenue
- Limassol, Lim,
CY, CY-3608
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- TEL:35725362818
- FAX:35725359262
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