I hereby certify that I am the true and legal owner of the following credit card.
Credit Card #:
Expiration Date (mm/yy):
You are authorized to charge this card for an amount of $
Name as it Appears on the Card:
Billing Address of the Card:

City:
State:
Province:
ZIPor Postal Code:
Country:
I hereby acknowledge receipt in good order of the services described in this invoice, and I irrevocably waive my right to dispute this charge at a later date. I further understand that this electronic transmission is as binding as a signed document.