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Axis CC form for Production

1800 S. Wolf Road, Des Plaines, Illinois 60018 847 297 0744 [email protected]

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:

authorize Axis International Marketing, Ltd. to charge my credit &/or debit card, account number, indicated below for

$ on or after Date Select Date

This payment covers the Invoice number above.

Billing Address

Account Type:

Cardholder Name

Account Number

Expiration Date Select 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.

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Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

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Timestamp

Audit

September 18, 2023 1:37 pm CST

Axis CC form for Production Uploaded by Andy Berger - [email protected] IP 67.184.60.2

September 25, 2023 9:08 pm CST

Andy Berger - [email protected] added by Andy Berger - [email protected] as a CC'd Recipient Ip: 97.83.201.66

September 27, 2023 3:11 pm CST

Andy Berger - [email protected] added by Andy Berger - [email protected] as a CC'd Recipient Ip: 67.184.60.2

October 3, 2023 3:49 pm CST

Andy Berger - [email protected] added by Andy Berger - [email protected] as a CC'd Recipient Ip: 67.184.60.2

October 3, 2023 3:49 pm CST

Linda Berger - [email protected] added by Andy Berger - [email protected] as a CC'd Recipient Ip: 67.184.60.2