Credit Card Form - Citrix

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We, ___________________________________, authorize our credit card/debit card to be charged to
make our payment to Citrix Online from the account indicated below and post it to our Citrix Online
We understand that any changes on our credit card/ debit card will be given to Citrix Online no later than
of the month before the charge is made. If our credit card account declines because of various
the 25
reasons, we will be responsible for providing an alternative method of payment to Citrix Online. Thus, we
grant Citrix Online the right to discontinue service within two weeks of the due date.
Invoice Number____________________
Invoice Amount ($) __________________
Invoice Number____________________
Invoice Amount ($) __________________
Invoice Number____________________
Invoice Amount ($) __________________
Total ($) ___________________
Payment Currency Type: Euro
American Express
Visa Electron (IRE)
American Express UK
__ Please check here if you would like this payment to be recurring for your Citrix Online Account
Please use the COMPANY NAME and CITRIX ONLINE ACCOUNT NUMBER shown on invoice:
Company Name: _______________________________________________
Citrix Online Account Number: _____________________________________
Card holder name as it appears on the card: ___________________________________________
Contact Phone Number: __________________________________________
Billing Address: _________________________________________________
Card Number _________________________________
Expiration Date: mo: _____ yr:_____
As the authorized credit card holder, I agree to pay the total amount as entered above according to the
card issuer agreement.
_____________________________________________________ (Signature)
*For your safety and security, please do not send your credit card information to us via email. Please fax
this completed form to +1-805-690-2905.
6500 Hollister Avenue Goleta, CA 93117 * Ph: +1-805-690-6400 * Fax: +1-805-690-2905
Email Address:


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Parent category: Financial