Payment Authorization Form

Authorization Form

Customer Information

Customer Information

Credit Card

Payment Information

Section

By submitting this form, I certify that I am an authorized user of this credit card. As the cardholder, or corporate officer, I understand that I am authorizing Web Interactive Technologies to charge this card for services rendered. I understand that I am responsible for any additional charges that may arise from my credit card company and am responsible for informing Web Interactive Technologies of any changes to this form of payment immediately.