Credit card authorization form

 

 

 MPIS, Inc A Detective Agency
PO BOX 120
60 Chestnut Street Suite 02
New Creek, WV 26743
Telephone: 304-788-9040
 
 
Please print this - sign and complete this form and fax to us at: 304-788-9041 if you have no fax machine please mail to us.
  
 
I agree to pay MPIS, Inc and or sister company's the amount shown below by using my credit card (Visa, MC, or Discover) for services provided to me by MPIS, Inc. I understand that results will be sent to my email address if information, and results are located for the subject that I'm searching. I also understand that MPIS, Inc does not own the data that is provided to me in most cases, and I hold MPIS, Inc non liable for results provided. I also understand that I will only use the information that is provided to me for legal reasons under the GLB, IRSG, FCRA, local, state, and federal laws. All information below is required please fill in all information shown below.

 I ________________________________________(Your name) agree to pay charges for services rendered by MPIS, Inc using my credit card

Type of credit card:    (Visa)      (Master Card)       (Discover)    -Please circle one.

Amount to be charged to my card: $_______________

Credit card number: _______________________________________________

Exp date: ______________

CVV or Security code: __________________
The CVV or security number is the last set of numbers on the back of your credit card. This is usually
three numbers after your credit card number. (Some credit card company's may not use this yet)

Billing Address: _____________________________________ City: ____________________

State: _____________________ Zip code: ______________

The billing address is where you receive your credit card statements at. This is important
as we use address verification when we charge your card and the address must match.

Your telephone number: ___________________________ (Area code + number)

Signature: __________________________________ Date: ____________

Your email address: _____________________________________

I agree to pay the above charge using my credit card, and I agree that this is my card. The charge
on your credit card statement will show as MPIS, Inc.

Please fax this to: 304-788-9041