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Credit Card Authorization

SOULUTIONARY INC.
CREDIT CARD AUTHORIZATION FORM

Name: _______________________________________________________

Email: ________________________________________________________

Billing Address: _________________________

Billing City: ________________

State: __________

Zip Code: _____

Country: _________

Name on Credit Card: ______________________________________________ Type of Card: Visa __ Mastercard __ American Express __ Discover __

Credit Card Number: _______________________________________________ Credit Card AVS Code (on back of card 2 or 4 digit number)________________

Credit Card Expiration date: _________________________________________ Monthly Payment: _______for _______________

I authorize Prema Lee Gurreri - Soulutionary Inc. Business to charge the agreed amount listed above to my credit provided herein.

I agree that I pay for this purchase in accordance with the issuing bank cardholder agreement.

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Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

August 14, 2023 6:00 pm PDT

Credit Card Authorization Uploaded by Prema Lee Gurerri, President Soulutionary, INC - prema@soulutionary.com IP 66.115.149.31