PIXELPOPS DESIGN, LLC CREDIT CARD AUTHORIZATION FORM
718 W. Arapaho #90, Richardson, TX 75080 billing@pixelpops.com
Please print out, fill out, and FAX this form to authorize credit card billing
for any charges due on your PixelPops Design account.
FAX to 972-234-0053.
Card Type
(circle one): MASTERCARD VISA AMERICAN EXPRESS
Card Number: _____________________________________
Expiration Date: _______ /_______ /________
Card Holders Name: ________________________________
(exactly as it appears on the credit card)
Company Name: ______________________________________
Billing Address: ______________________________________
City: ______________________________________________
State: __________________ ZIP: __________________
Card Holder Phone Number: ( ) ________-______________
Card Holder Signature: __________________________________
Card Holder Name (PRINT): ______________________________
Date of Signature: _______ / __________ / _____________
Bill charges due for:
[ ] Hosting
[ ] Domain Registration/Renewal
[ ] Web Design
[ ] Other ________________________________
FAX to PixelPops Design at 972-234-0053.