Date

Card type AmexDiscoverMastercardVisa

Account#

Name on card

Street Address

Zip

I the cardholder, authorize Emdee International to charge the above payment. I agree to pay this amount in full and understand that this payment is FINAL and no chargebacks will be allowed.

Authorized name of card holder

Please note that this is only an authorization to charge, not a payment. The actual payment will be processed by our office and you will receive an emailed receipt of the transaction within 12-24 hours.

A 3% surcharge is added when paying by credit card.