CREDIT CARD AUTHORIZATION FORM| DTI SERVICES

CREDIT CARD AUTHORIZATION FORM

THIS FORM CONFIRMS YOUR REQUEST FOR PAYMENT BY CREDIT CARD. BY SUBMITTING THIS FORM, YOU AGREE TO PAY ANY AND ALL AMOUNTS CHARGED BY DTI SERVICES, INC. AND/OR, DI SERV CORP, LTD. TO YOUR CREDIT CARD ACCOUNT SPECIFIED BELOW, AND AUTHORIZE DTI SERVICES, INC., AND/OR DI SERV CORP, LTD. TO OBTAIN CREDIT APPROVAL FROM SAID CREDIT CARD COMPANY.

I HEREBY AUTHORIZE DTI SERVICES, INC., AND/OR DI SERV CORP, LTD. TO CHARGE MY CREDIT CARD ACCOUNT SPECIFIED BELOW. I AFFIRM THAT I AM AT LEAST 18 YEARS OLD AND THAT I AM LEGALLY AUTHORIZED TO USE THE CREDIT CARD ACCOUNT NUMBER SPECIFIED BELOW. FURTHERMORE, I UNDERSTAND AND AGREE THAT ANY CHARGES MADE TO THE ACCOUNT SPECIFIED BELOW ARE FULLY NON REFUNDABLE, AND I AGREE TO PAY, PURSUANT TO MY AGREEMENT WITH SAID CREDIT CARD COMPANY, ANY SUCH AMOUNTS CHARGED BY ME BOTH IN THE PAST AND HENCEFORTH. ADDITIONALLY, I AGREE TO HOLD DTI SERVICES, INC., AND/OR DI SERV CORP, LTD. COMPLETELY AND FULLY HARMLESS FROM AND AGAINST ANY AND ALL CLAIMS OF ANY TYPE OR NATURE WHATSOEVER RESULTING FROM ANY CHARGES MADE TO SAID CREDIT CARD ACCOUNT PAYMENT, IN FULL, WILL BE BILLED TO THE CREDIT CARD SHOWN BELOW.

Credit Card Information

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CREDIT CARD TYPE:
VISAMASTERJCBDINERS CLUB

CREDIT CARD (First 6 Digit):

CREDIT CARD (Last 4 Digit):

EXPIRATION DATE:
/

CARD HOLDER NAME:

BILLING PHONE NUMBER:

COUNTRY:

ZIP CODE:

STATE:

CITY:

STREET ADDRESS:

Personal Information

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USER INFORMATION:

EMAIL:

Same as above (tel and address)

CURRENT PHONE NUMBER:

COUNTRY:

ZIP CODE:

STATE:

CITY:

STREET ADDRESS:

PER MY REQUEST THROUGH THEIR ONLINE CREDIT CARD PROCESSING SYSTEM, I HEREBY AUTHORIZE DTI SERVICES, INC., AND/OR DI SERV CORP, LTD. TO CHARGE ON THE ABOVE CREDIT CARD ACCOUNT.