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Card Authorization

Consumer Connect Program

Company Name: _____________________________________

Contact Phone Number: _______________________________

Company Email Address: ______________________________

Please mark the type of card you authorize for this transaction:
Visa___ MasterCard___ AMEX___ Discover___

Credit Card Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __

Security Code/ CVV2 Code : ____________ (three or four digit code on back or below
CC# in front)
Expiration date on Credit Card: ___________________________

Credit Card Statement Address (must match the address shown on credit card
statement).
_________________________________________________________
_________________________________________________________
_________________________________________________________

Phone number of Credit Card Holder: (_____)_____________________

Please charge this Credit Card $_______ per lead/appointment until I send you written
notice to quit. You may charge up to $______ total per week.
Current TV (Transaction Value): ________

Description of offer/question for prospective clients:


___________________________________________________________________________
___________________________________________________________________________

Name of cardholder: (signature) ____________________________________

Name of cardholder: (printed) _____________________________________

Date of signature: ______________________________

After acceptance into Consumer Connect Program, cardholder (and/or company) will be
provided with "test" contacts, if cardholder is unhappy with results Provider may
remedy/replace or issue refund. Cardholder is protected by money back guarantee, an
attempted chargeback will result in an immediate $500 fine to cardholder's card, this
agreement servers as Proof of Deliver and any and all problems that arise must be settled
through arbitration with stated attorney ________________________. This agreement may be
used in conjunction with Policies Agreement if provider chooses.