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