Harris Internet Services, Inc.
(Wedding Yellow Pages.Net)
496 West Saint Charles Rd.
Elmhurst , IL 60126-3128
Tel. 630-563-9740
Fax 630-359-4387
CREDIT CARD CHARGE AUTHORIZATION
Please mail or fax this completed form to Harris Internet Services, Inc.
I, the undersigned, authorize Harris Internet Services, Inc. to do the following:
1. Keep my signature on file;
2. Charge my MasterCard ® or VISA ® account as indicated below;
3. Automatically charge my account the same amount in the same way on each anniversary of today, unless I notify Harris Internet Services, Inc. of my cancellation in writing 30 days prior to the anniversary date.
___________________________________________________________
Cardholder Name
___________________________________________________________
Cardholder Billing Address
_______________________________ _________ _________
City State Zip
(Visa/MC) _________________________________ ______________ _____ _____
Account Number Month Expiration Year VC
_________________________________________ ____________________
Cardholder Signature Date
Choose Payment Method:
( ) Charge my account $99.00 for one annual payment.
( ) Charge my account $33.00 per month for 3 consecutive months as my annual payment.
(1-17-2005)