WBMTT INC. Credit Card Authorize Payment Form

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What is your email Address?

Name as it appears on the Card *

Last Name as it appears on the Card : *

Billing Address on File with your Credit Card Company *

Street Address Line 2

City *

State/ Province *

Zip Code *

Country *

Phone Number associated with the card *

Credit Card Information

Credit Card Number *

Expiration Month *

Expiration Year *

CVV SecurityCode. This will be the 3 digit code on the back for Visa, MC, Discover or the 4 digit code on the front of American Express. *

By Initialing Below I certify that all information provided is true and accurate. *

By Submitting this form I am signing with my unique IP address that I am the cardholder, authorized to make purchases on this card ad by filling out this form I am authorizing to be billed for services received.

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