Credit Card Authorization
For your protection, we do not take credit card information on the website. If you wish to pay by credit card, please complete the form below, print and fax to 323-932-0321.

DO NOT send credit card information in the mail. Please indicate on the form if you wish to have a paid receipt mailed to the address you specifiy below.

Please note: Your contract and materials must be sent by U.S. Mail or private carrier to to the address specified on the contract, making note on the contract that your fee has been paid by credit card.

Name: (as it appears on the card): _______________________________

Address1: _______________________________

Address2: _______________________________

City:_______________________________

State: _______________________________

Zip Code: _______________________________

Email: _______________________________

Telephone number we should call if there is a problem with your card
(Please indicate the best time to reach you) _____________________

Amount you wish charged to your credit card: ______________

Service you are purchasing:(Launch Analysis, 20 Hours Editorial Services, etc. ) ______________


Card Type: _______________________________

Card # _______________________________

Expiration Date: _______________________________

AVS Code (3-digit number on back of card) ______

Receipt: Yes: ______ No: ______

My contract and materials are enroute: ________

My contract and materials will be sent: (Date) ______

By signing this form, I authorize The Writer's Lifeline, Inc. to charge the credit card specified above the fees stated for the service purchased.

Signature__________________

Date___________

 
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