Cybercon Credit Card Authorization Form
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* Customer ID:___________________________________________________________________________ * Company Name:__________________________________________________________________________ * Contact Name:__________________________________________________________________________ * Credit Card Type: _ Visa, _ Mastercard, _AMEX, _ Discover, _ Dinners Club * Credit Card #:__________________________ Security Code:_________ * Card Expiration Month (mm):_________ Expiration Year (yyyy):__________ * Is it a Debit card? _ No. _ Yes * Cardholder First Name:__________________ Last Name:_______________________ * Card billing Street Address: City:_____________________________ State:___________________________ Country:__________________________ Zipcode:_________________________ * Does the cardholder authorize for recurring charge in the future? (a) if yes, please check here: ____ (b) if no, please specify the U.S. dollar amount that you authorize for: _________ * Credit card issuing bank phone number:____________________________________ * The cardholder agrees that Cybercon will automatically bill the subscriber's credit card each term specified above until the subscriber notifies Cybercon in writing to either cancel the account or stop credit card billing 30 DAYS prior to the first day of the month. Otherwise, cardholder will be responsible for current month service payment. Customer shall provide notification of its termination of the Service by sending such notification via the web form at https://clients.cybercon.com or certified United States Postal Mail, postage prepaid. * Cardholder signature (MUST BE IN HAND WRITING): * Date signed: Thank you for your cooperation & your business. Please fax this form to: 1.314.241.1777. Or postal mail it to: Cybercon 210 N Tucker Bvld, Suite 700 St. Louis, MO 63101 USA We thank you for your business.