Credit Card

Authorization Form

Please initial, fill out the payment information below and send to us.

By signing this you understand that this amount is nonrefundable and will be charge to your credit card or debited from your checking account.

Your First Name

Your Last Name

Amount

Name on the Credit card

Credit Card Number

- Expiration Month -

- Expiration Year -

Security Code

Address

ZIP / Postal Code

Your Phone Number

Your E-mail Address (optional)

I give Utech Digital permission to charge my debit or credit card (details above) for the amount initialed above.

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