Credit Card Authorization.
Please fax it to 1-800-250-2611 (or) 1-705-792-2025 (or you can mail this to us or scan and email this to us)

For security purposes, any information submitted will be subject to verification.

All fields are required [PLEASE PRINT]

• Your account number with us: _______________________

• Name on ad: _______________________

Credit Card Billing Address

• Card Holders Full Name (as it appears on the card): _______________________

• Phone Number: _______________________ (Must be the CARD HOLDERS phone number - we will call to verify)

• Billing Address of card: _______________________ (This MUST be exactly where the card is billed)

• City: _______________________

• State/Province: _______________________

• Postal Code / Zip code: _______________________

• Credit Card Number: ________________________________

• Type of Card:    VISA  MC        (Visa & MC Only at this time)
  

• Expiration Date:   ____  / ______

• CVS/CVV2 ____ (On the back of your card is a string of numbers - we need the last three numbers)

• Amount: $______________________

We need the actual card holders signature on file to further prevent chargebacks and fraud



I (Print Name) _______________________ Authorize DeSign Co. to bill my credit card. I understand that DeSign Co. keeps my personal information on file and I can request to remove this after 12 months time.

I also give authorization to accept this credit card for future payments if I supply the last 4 digits of my card number along with expiry date and my name as it appears on my card by either email or phone call (YES or NO). Initial Here _____




Signature of card holder: _____________________ Date:__________

Your statement will show billing by "DE SIGN"