Super Technologies, Inc Credit Card Authorization Change
Super Technologies, Inc Credit Card Authorization Change
|Type of Service and Order Number: | |
|(Example: Superphoneunlimited 101099) | |
|Card Holder's Name | |
|Credit Card Billing Address: | |
|(Example: 15 W Strong St, Ste 10C, Pensacola, FL 32501) | |
|Country | |
|Credit Card Type (Circle please.) |Master Visa AMEX Discover |
|Credit Card Number | |
|Expiration of Credit Card | |
|Card Verification # (4 extra digits on front of AMEX or 3 extra digits on| |
|back of other) | |
|Issuing Bank (in case of MC or Visa) | |
|Billing Telephone: | |
|Other telephone where you can be reached. | |
|Email Address: | |
|Name of previous owner of this Super Technologies, Inc. account: | |
|(Fill this when ownership of Super Technologies account changes.) | |
Change of Credit Card: I authorize Super Technologies, Inc. to charge the my credit card for Super Technologies, Inc. Services
I verify the above information is correct. I understand that all payments are non-refundable. I agree not to use Service for any unlawful or destructive purposes or in such a way to create damage or risk to Super Technologies, Inc. business, reputation, employees, facilities, third parties or to the public in general.
My signature __________________________________ Date ________________
Please fax this form filled and signed to 1-800-357-2230 or 1-206-339-4203 with the clear copies of the front and back of the credit card, 1st page of last credit card billing statement showing the billing address and name, and a photo ID (must match the billing address and name on credit card statement).
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