Contact Information

Required in the event that there are issues with your form submission and we must contact you.

Business Name(Required)

Contact Email(Required)

Contact Phone

Credit Card Authorisation Form

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorisation will remain in effect until cancelled. This information will be processed by Square, Inc. and may be stored by them in the United States and other countries.

Cardholder Name(Required)

Name as shown on card.

Card Type(Required)

Visa

Mastercard

American Express

Credit Card Number(Required)

16 numbers only - no spaces or dashes

Credit Card Number(Required)

15 numbers only - no spaces or dashes

Expiry(Required)

CVV/CVC(Required)

Security code on back of card.

Postal Code(Required)

Postal Code

Must be code used for billing address.

The cardholder named above authorizes Smashing Pixels to charge the credit card above for agreed upon purchases. Cardholder understands that information will be saved to file for future transactions on my account. Smashing Pixels will not store any information on a server or the internet.

Signature(Required)

Date(Required)

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