I,_________________________________________authorize______________________________________
                                                                                                                                                     (Company)

to charge the amount of ($)___________________ for the following services:___________________________

to my (please tick): _______Visa, _______Mastercard, ________Amex, _______Diners/Enroute, _____Discover:

Card #____________________________ Expiry date:___________Cardholder

Signature:_______________________Date:_________

I/we are aware of any cancellation policies and agree not to dispute or attempt to Chargeback any of the above signed for and acknowledged charges

______________
(Cardholder initial)