Credit Card Authorization Form

PLEASE PRINT OUT AND COMPLETE THIS AUTHORIZATION AND RETURN TO US.

All information will remain confidential.

Cardholder Name: ___________________________________________

Billing Address: ______________________________________________

___________________________________________________________

Credit Card Type: _____ Visa _____ MasterCard ____ Discover

Credit Card Number: __________________________________________

Expiration Date: ______________________________________________

Card Identification Number (last 3 digits located on the back of the credit card):

________

Amount to Charge: as per valid agreement between Cardholder and Elevare Dispatching Services LLC.

I authorize Elevare Dispatching Services LLC to charge the agreed amount listed above to my credit card provided herein. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement.

Cardholder – Print Name, Sign and Date Below:

Signed: ___________________________________________

Print Name: ________________________________________

Dated: ____________________________________________