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. |