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Credit Card Authorization Form
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* Indicates required question
This charge is authorized for:
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Recurring (Monthly, until Card or Account Status Change)
Authorized Charge Amount:
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Company Name
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Your answer
Credit Card Issuer
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Visa
MasterCard
AMEX
Discover
Credit Card Number
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Your answer
Verify Credit Card Number
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Expiration Date
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Security Code
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Name on Card
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Address 1
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Address 2
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City, State, Zip Code
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By submitting this form, you acknowledge you are authorizing GetTheReferral.com Inc. to charge this card in the amount indicated.
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Yes, I, the authorized company agent, agree and approve this transaction.
No, I am not the authorized company agent.
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