yourdailyvibe.com

Credit Card Processing Information

After filling this form out fax back to chiroschool.com

 

Fax----707-939-7153

 

 

I,                                                          , hereby authorize chiroschool.com ,to charge the following credit card account in the amount shown below for merchant services. This payment agreement will be in effect until services have been completed or are ended by request of the client either verbally or in writing.

 

Please print very neat I beg you!

 

Credit Card Information: All fields need to be filled out

 

Card Type:                  Visa                           Mastercard

 

Card Number:                                                                                                

 

Expiration Date:                                                                                             

 

3 digit card code on back of card__________________________________

 

Name on Card:                                                                                               

 

Billing Address:                                                                                             

Street or P.O. Box

                       

                                                                                                                       

                        City,                                        State                            Zip

 

Telephone # ________________________________________________

 

E-mail Address:                                                                                             

 

Amount:                                 

 

Billing Cycle:                                     

 

Cardholder’s Signature:                                                                                 

 

After filling this form out fax back to chiroschool.com

 

Dr Lenny Cocco                              

Phone-707-939-0377

Fax----707-939-7153

drlenny@chiroschool.com                       Thank You !