Venus Advertising Credit Authorization Form

Venus Advertising Service.
PO Box 260594
Lakewood CO. 80226
T: 303.988.5129
F: 303.984.4281

Credit Card Authorization Form

If your credit card has a foreign billing address, please use this form for credit authorization.

Rules:
(1) Please fill out this form after placing your order.
(2) You have to fill out this form and fax once you have received your client number from your sales representative.
(3) We cannot guarantee that your advertisement will be placed immediately after receiving this form by fax. Further verification, although rare, may be necessary under some situations.

I hereby authorize Venus Advertising Service to charge my credit card in consideration for the advertisement(s) I have placed with them. I understand and agree that this authorization is in lieu of my signature on an actual charge draft or carbon copy voucher.

I further understand that there will be no refunds to my credit card, and all ad sales are final.

Please pick a payment option:

1. I authorize a total amount of $_____.00 USD per month, or $______.00 USD quarterly, until such time I discontinue my advertising by notifying publisher in writing. This amount is saved on file for future charges (your representative will notify you prior to charging your credit card for future payments).

OR

2. I authorize a total amount of $______.00 USD one time charge on my credit card (future charges will require you to fill out a new credit card form).

Card Type: ___________
Card Number:_____________________________________
Exp Date: __________

Name exactly as it appears on card: __________________________

Card Billing Address:

__________________________________

__________________________________

City: _______________________
Province/County: ______________________
Postal Code: _____________

Telephone: ___________________

This authorized charge is in consideration for the advertisement placed on the following account with Venus Advertising Service, LTD:

By signing below, I agree that a facsimile copy of this authorization shall be as valid as the original.

Cardholders Signature: __________________________________

Account Number: _______________________

 

(Office Use Only) Authorization Number: ____________
Receipt Number: ____________