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.