EmailMeForm
Credit Card Authorization for ALL MAVEN
Complete this form to not only store your card information with ALL MAVEN, but also to serve as your authorization. When you say, "please bill this to my account", we will reference this data to make charges appropriately.
Name
*
First
Last
Phone
*
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Business
*
Email
*
Payment Data
Enter the Following Data to allow ALL MAVEN to securely store your credit card information. This form is completely secure, utilizng masked entry, field encryption as well as SSL Encryption.
Cardholder Name
*
First
Last
Card Number
*
CVV
*
Expiration Date
*
MM
/
YY
Billing Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
How should we handle your card information?
*
Keep this card on file for potential future purchases, I'll let you know when I'd like to use it
Make this my primary card and charge this card for all future invoices to my account unless otherwise stated
Other
ALL MAVEN WILL NOT BILL TO ANY CARDS WITHOUT YOUR PRIOR CONSENT. SIMPLY BECAUSE YOU USE SERVICE WILL NOT TRIGGER US TO CHARGE YOU. YOU WILL ALWAYS RECEIVE AN INVOICE PRIOR TO A CHARGE AND MUST LET US KNOW HOW YOU'D LIKE TO BE BILLED.
If you currently have outstanding invoices, would you like us to pay these now with this information you have provided?
Yes
No
N/A
Other
Consent
By checking the box below, you have provided your consent and authorization. If you'd like to remove consent, this must be submitted to our office in writing and at least 24 hours in advance of pending charges.
I certify that I am authorized to provide the included card information on behalf of our company. I further authorize ALL MAVEN to store my card information on file and to make purchases using this card where consent is appropriately given.
*
Yes
Signature
*
Clear
Questions/Comments