Credit Card Information Survey

CREDIT CARD AGREEMENT

By completing and submitting this form, I authorize Give Obesity the Boot™, Inc., to charge my credit card for WLSS One on One Coaching, Sponsorship, Membership, and/or Donation. I agree that any dispute(s) will be resolved no later than ten (10) days from the day of the charge.

* Require Answer to Question

*
Type of Card

Type of Card Visa

Master Card

American Express

Discover

Payment Arrangements
If you have made payment arrangements with Angie Flores, please specify the arrangements and dates of payments.

Payment Arrangements If you have made payment arrangements with Angie Flores, please specify the arrangements and dates of payments.

*
Completed By

Completed By Name / Member ID
$ Amount to be charged
Credit Card Number
3 digit security code
Expiration Date

*
Billing Address

Billing Address Name as shown on card:
Company:
Address:
City:
State/Province:
ZIP/Postal Code:
Email Address:
Phone Number:

Group Name
If you joined as a group member

Group Name If you joined as a group member

*
Authorized Signature on Card

Authorized Signature on Card Yes charge my credit card for the amount above.

*
Sign and Date: Typing my name and today's date will serve as my digital signature for the purpose of authorizing Give Obesity the Boot, Inc. to charge my credit card for WLSS One on One Coaching, Membership, Merchandise and/or Donations.

Sign and Date: Typing my name and today's date will serve as my digital signature for the purpose of authorizing Give Obesity the Boot, Inc. to charge my credit card for WLSS One on One Coaching, Membership, Merchandise and/or Donations.

Credit Card Information

CREDIT CARD AGREEMENT

*Type of Card

Payment ArrangementsIf you have made payment arrangements with Angie Flores, please specify the arrangements and dates of payments.

*Completed By

*Billing Address

Group NameIf you joined as a group member

*Authorized Signature on Card