Customer Information

Customer Name: Date of Application: 01-01-1970
Phone: Email:
Purchase IP Address: Authorization IP Address:
Billing Address:


,
Shipping Address:



,

Credit Card Information

Name on Card: Card Type:
Card Number: XXXX-XXXX-XXXX- Exp Date: /
 
I, , hereby authorize Satmodo, LLC (Satmodo), via this signed authorization, to charge the above credit card for the amount of $ for all products and services I purchased and requested.

As the credit card holder, I hereby authorize receipt of goods & services at the shipping address listed above.


Digital Signature
You are confirming from this IP address:18.234.236.14

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