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Credit/Debit Card Payment and Change of Card Form
Personal and
Company details
First Name*:
*
Last Name*:
*
Company Name:
E-mail*:
*
Phone:
*
Billing
Address:
Address:
Address (line2):
City
State
Zip/Postal Code
Country
Payment
Details:
Name on credit card:
Credit card number
Expiration Month
Expiration Month
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
Expiration Year
Expiration Year
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
Security code:
Amount:
Service Note:
Hidden
IP
Untitled
*
I hereby authorize Offix Solutions LLC to use the above credit card for payments using this form. I agree that I will pay for this service and indemnify and hold Offix Solutions LLC harmless against any liability pursuant to this authorization.
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