123bingo.com Credit Card Authorization Form


Date: _______________________________________________.


Name: ______________________________________________.


Card number: _________________________________________.


Card Number: _________________________________________.


Expiration Date: _______________________________________.


I hereby authorize online purchases to be made with the above card, and agree to pay for my deposits as stated on the issue agreement for the respective card. By signing this form, I acknowledge my purchases at www.123bingo.com may be displayed with the following descriptor.

123bingo.com SUBONSERV VIBINGO

SERVICIOS DE INTERNET. SAFEPAYCARD.COM

In order to comply with Visa and MasterCard regulations, I enclose a copy of both sides of the credit card mentioned above, as well as a proof of ID stating my exact name, address and signature providing authorization for all my purchases at www.123bingo.com.

I agree to the above terms and conditions as stated by 123bingo.com





______________________________
Customer’s Signature.