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VISOX.COM Credit Card Authorization Form
VISOX.COM
accepts Visa, Mastercard, American Express and Discover as a payment
option. To have you credit card charged for VISOX.COM services
we MUST have the following signed statement on file. Accounts will
be charged on the invoice date.
All fields are required:
Name (as it appears
on the credit card):
_______________________________________________
Address where CC statement is received:
_______________________________________________
City: ________________State/Prov: ______Zip:________
Country:_________
Domain Name/Username: __________________________
Email Address: _______________________________________
Phone number:_______________________________________
Card type (Visa, MC, AmEx, Discover): ____________________
Card number:________________________________________
CIN
(The Card Identification Number
is a 3- or 4-digit number that's typically printed on the back of
a credit card, on the right-hand side, but not part rt of the credit
card number itself. The American Express number is found on the front
of the card. Visa calls this value CVV2,MasterCard calls it CVC2,
and American Express calls it CID. This value only appears on the
card itself (not on receipts or statements)so it can provide some
indication that the physical card is in the possession of the buyer.The
Card Identification Number)
___________________
Expiration month/year:___________________
I authorize VISOX.COM to charge my Visa/Mastercard/American
Express/Discover account for charges for VISOX.COM service that
I may accrue from month to month or any past due balances in order
to bring the account in current status. I further agree that I will
not dispute (chargeback) these charges. This authorization is valid
until revoked in writing.
Authorized signature: ___________________________________
This form MUST be either mailed or faxed to VISOX.COM
immediately in order for your account to be started on our servers.
This process is included to protect both you
and VISOX.COM. Credit card charges will appear on your statement as
VISOX.COM
Fax to: 909.954.9570
or Mail to:
VISOX.COM
22365 Barton Road
Suite 309
Grand Terrace, CA 92313
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