Response Audio Co. LLC
112 Carl Street, Endicott, New York 13760 Phone: (607) 785-3440 FAX: 1 (607) 785-3800
Credit Card Authorization Form
I, __________________________________________ , hereby authorize Response Audio Co. LLC to
charge my credit card in the amount not to exceed: $___________________________
( ) VISA ( ) MASTER CARD ( ) AMERICAN EXPRESS ( ) DISCOVER
Credit Card Number: __________________________________________________________
Expiration Date: MM ________ / YR__________ VID Code __________________
Name of issuing Bank:____________________________ Bank Ph.#________________________
Credit Card Billing Address:
Name: _______________________________________________ (as it appears on card)
Street: ______________________________________________________________________
______________________________________________________________________
City: ___________________________________________ State: _____________________
Zip Code: ______________________ Country: ____________________________________
Telephone: _________________________ ____________________________________
Email Address: _______________________________________________________________
Response Audio Co. LLC can only ship to the billing address of credit card provided on international orders. No exceptions.
As the credit card holder, I hereby authorize receipt of good & services at the address above.
_______________________________________________ _____/_____/_____
Cardholder’s Signature Date
As the credit card holder, I authorize Response Audio Co. LLC to charge credit card above for future purchases verbally approved by me.
Future Use Authorization Valid Until: _______ / ________ Initial Here: ______________
Your completion of this authorization form helps us to protect you, our valued customer, from credit card fraud. Response Audio Co. LLC will keep all information entered on this form strictly confidential.
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