Credit Card Authorization Form

Nvision.com, Inc.                       Telephone:  484-661-7664
1636 N. Cedar Crest Blvd, PMB 320     Fax: 610-841-2016
Allentown, PA 18104                     Email: billing@nvision.com
USA

Credit Card Transactions
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Thank you for placing your order with Nvision.com, Inc. 

If you would like to use a Mastercard, Visa, or American Express credit
card as payment for your Nvision account, please provide the following
information. A release signature should be included. You may mail it to
the above postal address, or fax it to 610-841-2016. Customers outside 
the USA should fax it to (001) 610-841-2016. 


Domain Name:            ______________________________

Card Type:              ______________________________

Card Number:            ______________________________

Expiration Date:        ______________________________

Name on Card:           ______________________________

Billing Address:        ______________________________

                        ______________________________

Email Address           ______________________________

 
? I verify that I am the legal owner of the above credit card, and all 
  information required has been filled out completely and correctly.
? I give Nvision.com, Inc. permission to charge my credit card for the amount 
  due each month until I submit written cancellation of my account.


___________________________                                      
Signature


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Date