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.
