Secured Credit Card Authorization

Authorization for Credit Card Use

PLEASE COMPLETE THIS AUTHORIZATION FORM.
All information will remain confidential

Name on Card:

E-mail

Billing Address:

Country

State

City

Zip

Credit Card Type:

Credit Card Number:

Expiration Date:

Card Identification Number:

Terms / Charges:

AdWords budget:

I authorize SeoSamba Corp. to charge the fees according to the terms set forth above.

I understand this contract auto-renews for a subsequent 3 month term after the initial term is completed when charges are recurring, unless I cancel services in writing during the previous term.

Date:

Signature: