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  • By: Signed Dated Print Name Authorized Card (1) CARD NUMBER: EXPIRATION DATE: CARD ... ·  · 2017-04-10CREDIT CARD AUTHORIZATION FORM Email this Form along with copies of the following
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CREDIT CARD AUTHORIZATION FORM Email this Form along with copies of the following to [email protected] 1) Color copy of Passport or Driver license of Accountholder (both sides). 2) Color copy of valid Passport or Driver license of the card holder of each authorized credit card 3) Color copy of Authorized Credit Card(s) (both sides). 4) Color copy of a Utility Bill, bank statement or credit card statement, not older than two (2) months Intertops Logon User Name or Customer Number Date Intertops Accountholder Name Accountholder Contact Telephone #1 Intertops Accountholder Street Address, Unit/Suite/Apt Number, City, State, ZIP Accountholder Contact Telephone #2 By signing below, I authorize the use of the following credit cards ("Authorized Card(s)" for loading my Intertops account identified above. I also agree that I have been authorized to use all of the Authorized Card(s) listed below and agree to pay any and all charges incurred by these cards to fund my Intertops account, regardless of when or by whom the transaction was authorized. I agree that you shall be fully protected in honoring any such Authorized Card(s) payments. I further agree that if any such Authorized Card(s) payment be dishonored, whether with or without cause and whether intentionally or inadvertently, you shall be under no liability whatsoever, including any fees imposed by my bank, even though such dishonor may result in the inaccessibility of my Intertops account. By: Signed Dated Print Name Authorized Card (1) CARD NUMBER: EXPIRATION DATE: CARD TYPE CARD BILLING ADDRESS: (if different than above) CARDHOLDER'S NAME (as it appears on the credit card) SIGNATURE OF CARDHOLDER TODAY'S DATE Authorized Card (2) CARD NUMBER: EXPIRATION DATE: CARD TYPE CARD BILLING ADDRESS: (if different than above) CARDHOLDER'S NAME (as it appears on the credit card) SIGNATURE OF CARDHOLDER TODAY'S DATE Authorized Card (3) CARD NUMBER: EXPIRATION DATE: CARD TYPE CARD BILLING ADDRESS: (if different than above) CARDHOLDER'S NAME (as it appears on the credit card) SIGNATURE OF CARDHOLDER TODAY'S DATE Authorized Card (4) CARD NUMBER: EXPIRATION DATE: CARD TYPE CARD BILLING ADDRESS: (if different than above) CARDHOLDER'S NAME (as it appears on the credit card) SIGNATURE OF CARDHOLDER TODAY'S DATE Question? Call 1-268-480-3100 P.O. BOX W247 Wood's Centre St. John's Antigua Tel: 1-268-480- 3100 [email protected] VISA MASTERCARD AMEX VISA MASTERCARD AMEX VISA MASTERCARD AMEX VISA MASTERCARD AMEX

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Page 1: By: Signed Dated Print Name Authorized Card (1) CARD NUMBER: EXPIRATION DATE: CARD ... ·  · 2017-04-10CREDIT CARD AUTHORIZATION FORM Email this Form along with copies of the following

CREDIT CARD AUTHORIZATION FORM Email this Form along with copies of the following to [email protected] 1) Color copy of Passport or Driver license of Accountholder (both sides). 2) Color copy of valid Passport or Driver license of the card holder of each authorized credit card 3) Color copy of Authorized Credit Card(s) (both sides). 4) Color copy of a Utility Bill, bank statement or credit card statement, not older than two (2) months

Intertops Logon User Name or Customer Number Date

Intertops Accountholder Name Accountholder Contact Telephone #1

Intertops Accountholder Street Address, Unit/Suite/Apt Number, City, State, ZIP Accountholder Contact Telephone #2

By signing below, I authorize the use of the following credit cards ("Authorized Card(s)" for loading my Intertops account identified above. I also agree that I have been authorized to use all of the Authorized Card(s) listed below and agree to pay any and all charges incurred by these cards to fund my Intertops account, regardless of when or by whom the transaction was authorized. I agree that you shall be fully protected in honoring any such Authorized Card(s) payments. I further agree that if any such Authorized Card(s) payment be dishonored, whether with or without cause and whether intentionally or inadvertently, you shall be under no liability whatsoever, including any fees imposed by my bank, even though such dishonor may result in the inaccessibility of my Intertops account.

By: Signed Dated

Print Name Authorized Card (1)

CARD NUMBER: EXPIRATION DATE: CARD TYPE

CARD BILLING ADDRESS: (if different than above)

CARDHOLDER'S NAME (as it appears on the credit card)

SIGNATURE OF CARDHOLDER TODAY'S DATE

Authorized Card (2) CARD NUMBER: EXPIRATION DATE: CARD TYPE

CARD BILLING ADDRESS: (if different than above)

CARDHOLDER'S NAME (as it appears on the credit card)

SIGNATURE OF CARDHOLDER TODAY'S DATE

Authorized Card (3) CARD NUMBER: EXPIRATION DATE: CARD TYPE

CARD BILLING ADDRESS: (if different than above)

CARDHOLDER'S NAME (as it appears on the credit card)

SIGNATURE OF CARDHOLDER TODAY'S DATE

Authorized Card (4) CARD NUMBER: EXPIRATION DATE: CARD TYPE

CARD BILLING ADDRESS: (if different than above)

CARDHOLDER'S NAME (as it appears on the credit card)

SIGNATURE OF CARDHOLDER TODAY'S DATE

Question? Call 1-268-480-3100

P.O. BOX W247 Wood's Centre St. John's Antigua Tel: 1-268-480- 3100 [email protected]

VISA MASTERCARD

AMEX

VISA MASTERCARD

AMEX

VISA MASTERCARD

AMEX

VISA MASTERCARD

AMEX

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