INNOVATIVE COMMUNICATIONS

7439 La Palma Ave., Buena Park, CA 90620 · Voice: 714-228-5400 · Fax: 714-647-1911

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 Holder must use their name and address as it appears on the credit card Statement. Invalid address is the main reason for rejection. This is for your protection. When this form has been completed you'll receive confirmation after you card has been process.

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

- The address used MUST be the Card Billing Address -

Please Print Clearly

Card Holder Information:

Card Holder's Name:

Card Holder's Address:

Card Holder's City: State: ZIP:

Telephone: Email: FAX:

Please check:

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.

One time payment in the amount of: $

Regular monthly payments as invoiced by Innovative Communications.

Please Email payment receipts to:

Card Type:

Credit Card Number: Expiration: Security Code:

Authorization Signed By:

Enter your comments in the space provided below:

Please contact me as soon as possible regarding this matter.

Copyright © 2008 Innovative Communications. All rights reserved. Revised: 03/26/08.