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Victoria's Agency - Credit Card Charge Authorization Form

Your full name:
The name on the card:	(only if different from above)
Credit card number:
Credit card expiration date:
Credit card billing address:	(the address where you receive this credit card's statements)
Your telephone number:
Is this:	home \| work \| cellular number? *(circle the appropriate)*
Alternative telephone number (optional):
Is this:	home \| work \| cellular number? *(circle the appropriate)*
Your email address (optional):
Your username on our site:	(if you don't have it, make sure you indicate your email address)
How many credits you want to purchase:
Your signature:
Date:

The price for credits depends on the amount you buy. You can choose the number of credits to purchase among the following options:

10 credits for $20

55 credits for $60

100 credits for $100

300 credits for $300

500 credits for $500

If the number of credits you prefer to purchase differs from the packages listed above please indicate another sum to be charged. The prices for credits are the following:

100 credits or more: $1 per credit

55-99 credits: $1.09 per credit

20-54 credits: $2 per credit

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