Tandem Instructor Re-Certification Form Page 3
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3CREDIT CARD AUTHORIZATION
Credit Card Number
_____/_____
_________
Expiration Date
Security Code
_____
_____
_____
_____
MC
Visa
Amex
Discover
__________________________
_______________________
Dealer/Customer Name
Sales Order/Invoice #
Name as it appears on Credit Card
Billing address for Credit Card – Street
City
State
Country
Zip
Phone Number for Credit Card Holder
I hereby authorize Uninsured United Parachute Technologies, LLC to
charge my credit card, number stated above, for the amount of
US$ _______________.
Your signature as it appears on your card_______________________
Or
I hereby authorize Uninsured United Parachute Technologies, LLC to
charge my credit card, number stated above, for any purchases I make
through Uninsured United Parachute Technologies, LLC
Your signature as it appears on your card _______________________
You MUST submit a new authorization if ANY information changes.
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