1800 S. Wolf Road, Des Plaines, Illinois 60018 847 297 0744 AXISMKT@AOL.COM
Credit &/or Debit Card Payment Authorization Form
Sign and complete this form authorizing Axis International Marketing, Ltd. to make a debit to your credit or debit card listed below.
By signing this form, you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a transaction to cover our Invoice # dated .
Please complete the information below:
I
authorize Axis International Marketing, Ltd. to charge my credit &/or debit card, account number, indicated below for
$ on or after Date
This payment covers the Invoice number above.
Billing Address
Street Address:
City, State, ZIP:
Account Type:
Cardholder Name
Account Number
Expiration Date:
CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX)
I authorize the above-named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company so long as the transaction corresponds to the terms indicated in this form.
