Kosmin Media Credit Card Authorization Form


Total: $ ____________________________________

Month to Month / Recurring:        Yes        No

Name on Card: ___________________________________________

Card Type: Visa   /   MasterCard   /   Amex   /   DSC

Credit Card Number: ______________________________________________

Three digit verification number on back of card: _________________

Note: We must have this number to process your card.
AmEx -- Use 4-digit number on front of card.

Expiration Date: Month: _________ Year: _____________

Address associated with this card:

Address: _____________________________________________

City: ___________________    State: ________    Zip: ______________


By signing below, I agree to pay the total price amount listed above according to the credit card issuer agreement:

Signature: ______________________________________________________

Print Name: _______________________________________________________

Phone Number: _______________________________________

Today's Date: __________________________

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Fax To:
281-754-4319

Or Return by Mail to:
Kosmin Media
562 Kingwood Dr, Ste 3
Kingwood, TX 77339