Card Holder Name: (as it appears on the credit card)

__________________________________________________________________

Check One: VISA ____ MasterCard _____ Discover _____

Credit Card Number: ______________________________________________

Expiration Date: Month _______ Year ________

Amount: $_______________

Card Holder Billing Zip Code: ___________________

 

Description of Item or Service: __________________________________________________

 

Email Address: _______________________________________________________________

Credit Card Holder Phone Number: _________________________

Print this form and fax (toll free) to Jim Reed at: 866-566-1283
Or
Call Jim Reed at one of the numbers below:
903-561-9887
903-258-1326