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Instructions

  1. Complete the form online and type all billing and shipping information in the blanks below, or print the form and complete the blanks legibly with a dark pen.
  2. Print the entire form and sign with the credit card holder's signature on the line indicated.
  3. Include a photocopy of the front and back of the signed credit card.
  4. FAX (1-877-446-6680) or scan and email the completed form and the photocopies of the credit card to complete your order.

 

Credit Card Authorization Form

  I, , hereby authorize Smart Multimedia Services dba Getyouawebsite.com to charge my credit card account in the amount of $ 
  VISA MasterCard American Express
Credit Card Number: 
Expiration Date:  /           Security Code:  (located on back of card)

Credit Card Billing Address:

Street: 
               
City:      State: 
Zip Code:  -
Telephone:  () -

Country: (if not US)  

Email Address:

Shipping Address (optional):

Street: 
               
City:      State: 
Zip Code:  -
Telephone:  () -

Country: (if not US)  

Email Address:

As the credit card holder, I hereby authorize receipt of merchandise at the shipping address and/or email address above.
__________________________________ ____/____/______
Cardholder's Signature Date

Please Highlight and Print This Form

Your completion of this authorization form helps us to protect you, our valued customers, from credit card fraud.  All information entered on this form will be kept strictly confidential by

Smart Multimedia Services dba Getyouawebsite.com.

 

 

COMPLETE OUR ONLINE WEBSITE QUESTIONAIRRE - CLICK HERE