Hmongitv Broadcasting
CREDIT CARD AUTHORIZATION FORM
I____________________________ the credit card holder hereby authorizes HMONGITV TO CHARGE MY CREDIT CARD OR DESIGNATED SUPPLIER BY HMONGITV TO CHARGE MY CREDIT CARD as per particulars below. I fully understand and agreed on the itinerary and restrictions on the product or Account(s) already Explained or Faxed/E-mailed to me by HMONGITV SALE REP. I am also fully responsible for any Charge back dispute and Non-payment to Credit Card Company or Issuing Bank.
Please verify all the names and dates and fill out this form and FAX BACK with the copy of your ID / DRIVER’S LICENCE & COPY OF THIS CREDIT CARD (BOTH SIDES). Customer(s) Name: __________________________ Product (_________________): Address: ________________________________________________________________ City/States/Zipcode________________________________________________________ International Phone: __________________________ other phone __________________ Email@Hmongitv: _________________@hmongitv.com other email: ______________ CREDIT CARD NO: _____________________________EXP DT: __/___Code_____ Name Billing Address if different than above: __________________________________ AMOUT TO BE CHARGED: $___________ Initial 1 One time: __________ On Call Payment: ________ Auto payment: _________ Approve: _____ Decline: _____ Reason: _________________ Return fund ___________
Referral: Yes ___________ No: _________ Name: ______________________ % _____ Date change phone ___________ Date effective _______ Date Expire _______ By signing here I have read and understand all the above. Name _____________________ signature: ___________________ Date _____________ Agent name _______________________ signature _____________________________
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