|
(PLEASE NOTE: we are not a credit card company. If this is regarding an "imagine" credit card, you have the wrong place.)
|
|
|
Credit Card Information
This form allows you to securely submit your credit card
information to us. If you have any specific questions,
please feel free to contact us via our contact system.
|
|
Name:
|
(as it appears on the card)
|
|
Company:
|
(as on card, if any)
|
|
Address:
|
(where bills for this card go)
|
|
City:
|
|
|
State:
|
(or Province, Country if outside USA)
|
|
Zip code:
|
(or Postal code if outside USA)
|
|
Type of card:
|
|
|
Card Number:
|
|
|
Expiration Date:
|
(mmyy)
|
|
CCV:
|
(the short number next to the signature area on the back)
|
|
Group:
|
(enter your account group name, if known, or "new" if new account)
|
|
Invoice Number:
|
(if paying an invoice, enter the invoice number here)
|
|
Auto Pay:
|
(if you would like this card to be billed automatically for future payments, enter the text "autopay" here)
|
Billing Email:
Same Again:
|
(if auto pay, or you are unsure of the contact email address we have on file, enter the eddress you want all communications to be sent, including billing receipts, here; twice to ensure accuracy)
|
|
