460 Van Emburgh Ave. Ridgewood, NJ 07450, USA
Tel: (646) 397-8728   Fax: (888) 781-8298
Email: service@visarite.com    Web: www.visarite.com

Credit Card Charge Authorization Form

    

I am a client of VisaRite Service Corp. I hereby authorize VisaRite to charge payment for following service to my credit card:
   Visa Service      Passport Service      Other Services

Service Request Confirmation #:
  Click here to get Service Request Confirmation Number
   
Card Number:      
   
Expiration date: /
   
Card Holder Name:
   
Card CVC (What's this?)  
  3 digits on the signature panel on the back of the card Visa,Master,Discover
   
Amount Authorized: + 3% credit card surcharge.
   
Billing Address:
City: State: Zip:
Date:
Tel:
   
I understand the government fee, VisaRite service fee and return shipping is non-refundable.
     
Signature:   <<< Sign Here
 
 
By sign this form, you indicate you have read and agree with the terms & conditions set forth by VisaRite.

 


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