| Name:
_________________________________
Service Address:
_________________________________
(street address)
_________________________________
(city, state, zip)
Daytime Phone
_________________________
(xxx) xxx - xxxx
|
Credit Card Information:
Account Number:
______--_______--________-______
Expiration Date:
______ / ______
(month) (year)
Credit Card Billing Address:
(if different from service address)
__________________________________
(street address)
____________________
(zip code)
|
| Please select
options by initialing your choice(s):
_____ I/we authorize DACOR
Computer Systems (DSC) to bill the above credit card account for all charges
currently owed.
_____ I/we authorize DCS to
bill the above credit card account on a monthly basis for all services
subscribed to until such time as my/our account with DACOR is terminated or
until this authorization is revoked by me/us in writing. |
Authorized
Signature(s):
_________________________________
____________________________________
Date:
______ / ______ / ______
(month)
(day)
(year) |