CREDIT CARD BILLING AUTHORIZATION

CREDIT CARD BILLING AUTHORIZATION

AFTER YOU SUBMIT THE FORM PLEASE FAX A COPY OF THE FRONT AND BACK OF THE CREDIT CARD TO 202-986-2064

Card Holder’s Name as it appears on card: *
Card Holder’s Billing Addresses: *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Card Holder’s Phone Number: * - (###) - ### ####
Credit Card: * Visa American Express Mastercard Discover
Expiration Date * / MM / DD YYYY
I authorize charges of transportation and service fee. *