CC Authorization – LM – Netsirv Production Site

AUTHORIZATION FOR CREDIT CARD PAYMENTS

Your Name

Company Name

Services Requested

Account Details

Card Name

Card Holder Name

Card Number

Expiration Date

CVC Code

Zip Code

Signer Account Details

Do you authorize Recurring Payments?

Authorization

I hereby authorize Local Motion, LLC, hereinafter called, to initiate debit and or Credit entries to the Credit Card account indicated in this form. I acknowledge and authorize, that if indicated, the Credit Card and account in this form will be used in recurring payments.

Signiture

Note: All written debit authorizations must provide that the debtor may revoke the authorization only by notifying the originator in the manner specified in the Authorization.

CANCELLATION NOTICE: This authorization is to remain in full force and effect until the NAMED above has given written notification of its termination.

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