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. The price for credits depends on the amount you buy. You can choose the number of credits to purchase among the following options: 10 credits for $20 55 credits for $60 100 credits for $100 300 credits for $300 500 credits for $500 If the number of credits you prefer to purchase differs from the packages listed above please indicate another sum to be charged. The prices for credits are the following: 100 credits or more: $1 per credit 55-99 credits: $1.09 per credit 20-54 credits: $2 per credit

1st International Marriage Network is our parent company