1. Please enter the required information and print the form.
  2. Sign and date the bottom of the agreement.
  3. Using your smart phone take a photo of the signed form, along with the front and back copies of your credit card(s).
  4. Take a photo of a valid government issued photo ID.
  5. Send us the photos of the signed completed agreement, credit card(s) and a copy of your government issued photo ID in JPEG or PDF format to [email protected].

Government Issued ID

(e.g. Drivers License)

Front and back of your credit card

 

 

To avoid processing delays, please ensure that the name, address, credit card number and signature on your submitted documents are clearly legible.

  • Month/Year

IMPORTANT: Please read the following carefully before signing and dating.

By submitting this signed and dated form, along with the additional information requested, I am authorizing and fully acknowledging that:

  • I acknowledge that this account was registered using my personal information and all transactions were initiated and authorized personally, using the above credit card.
  • I agree that all transactions made in my account will be paid in full.
  • I agree that any and all uncollected purchases or delinquent accounts are subject to 3rd party credit reporting and collections.
  • I am over 18 years of age.
  • I have read and accepted the terms described in the Transaction Processing Agreement.

Signature

Date

 

Email To

[email protected]

 

Reference No: