Innovative Communications can accept your Major Credit Card for payment of your services.   Because this is a “non-swiped” transaction, our card processor requires we obtain certain identifying information for your protection.  Please have the Card Holder use this form to authorize Innovative Communications to make charges as specified below.  The Card Hold must use their name and address as it appears on the credit card Statement.  This is for your protection.   When this form has been completed, please fax this entire page to 714-647-1911

NOTE:  THIS FORM MUST BE COMPLETED AND SIGNED BY THE CARD HOLDER

- The address used MUST be the Card Billing Address -

Please Type or Print Clearly

Credit Card Billing Name:

Address:

City:

State:

Zip:

Telephone Number:

FID or last four of Social Security  Number:

Please check:

o I hereby authorize Innovative Communications to make “non-swiped” charges to my credit card account for services ordered by me and rendered by Innovative Communications on my behalf in the amount allowed and frequency specified below.  I hereby agree to pay these charges according to my credit card company’s’ “Terms and Conditions of Use”.  This authorization will continue until written notification of termination by Innovative Communications or myself. 

o One time payment in the amount of:  $__________________

o Regular monthly payments as invoiced by Innovative Communications.

o Please Email or Mail payment receipts to: _____________________________

Card Number:  

Expiration:

3 digits code on Back of card:

Card Owner Signed:

  X

Today’s Date:

Print Name: