EmailMe Form - Credit Card Authorization for Logicopy

Name *

First Last

Phone *

### - ### - ####

Business *

Email *

Payment Data

Enter the Following Data to allow Logicopy 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 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

Use this card for recurring billing

Other

LOGICOPY 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 72 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 Logicopy to store my card information on file and to make purchases using this card where consent is appropriately given. *

Yes

Signature *

Clear

Questions/Comments