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Credit Card Authorization (Visa,…

Tags: american express, card number expiration, company address, credit card authorization, e mail address, expiration date, signature, visa mastercard, zip file,
Pages: 1
Language: english
Created: Mon Feb 25 11:03:16 2008
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                     Credit Card Authorization
              (Visa, MasterCard and American Express are accepted)



I authorize Jupitermedia Corporation to charge my credit card in the
amount of: Ninety-Nine Dollars ($99.00USD)

Company Name: ___________________________________________

Company Address: __________________________________________

________________________________________________________

E-mail address (where HM zip file should be sent): ____________________________

Type of card: ______________________________________________

Card Number: ______________________________________________

Expiration Date: ____________________________________________

Name on Card: _____________________________________________

Authorized Signature: ________________________________________

Notes: For license of: PLEASE FILL IN

____________WWW.___________________________________________________



                        Please return via fax to:
                               Barry Pullen
                     Manager of eCommerce & Licensing
                          HierMenusCentral.com
                          FAX # 203-547-6040