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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:

By signing this form I authorize the company "1st International Marriage Network" to debit my credit card the amount of US dollars for the above order.

(1-5 credits are $2 each

6-10 credits are $1.80 each

11-20 credits are $1.60 each

21-100 credits are $1.30 each

more than 100 credits are $1 each)

1st International Marriage Network is our parent company

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