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AutoPayment Authorization Click here to return to our website.
CREDIT CARD AUTHORIZATION FORM We require a Credit Card Authorization form on file to activate your participation in our AutoPayment service. Please PRINT and fill out this form. Then sign and fax to us. As soon as we receive the completed form we will activate your AutoPayment service. **Please do not send credit card information over the Internet. (Fax 619-582-4616) Please print clearly. Cardholder's Name:__________________________________________ E-mail Address:_____________________________________________ Cardholder's Address________________________________________ City___________________________________________ State (or Country)___________________________Zip_________ Daytime Phone: ________________________________ Date:____________________________ Credit Card Type: MASTERCARD_____ VISA_____AMERICAN EXPRESS____ Credit Card Number:__________________________________________________ Expiration:_____________ AMERICAN EXPRESS 4-DIGIT CID CODE_________________(Front of card) MASTERCARD/VISA 3-DIGIT CID CODE___________________(Back of card) Recurring MBF payment amount:___________ PLUS MESSAGE FEES
You hereby authorize Masterline Technologies, Inc. to charge your credit card for the recurring fees as stated above in compliance with your service contract. Masterline Technologies, Inc. 5305 Waring Road, San Diego, CA 92120 (619) 582-4616 Fax |