Credit Card Authorization


*I authorize Drinx Unlimited Inc., to charge the following credit card, any invoices on my account on the 15th of every month.  I may cancel this agreement, in writing, at any time.  However, I realize all unpaid balances must be paid in full at time of this cancellation.


Phone
Phone
Name for Billing of Credit Card
Name for Billing of Credit Card
Billing Address for Credit Card *
Billing Address for Credit Card
Credit Card *
Name On Card
Name On Card
Acts as Signature
Date *
Date
* for office personnel only