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CREDIT CARD AUTHORIZATION FORM Email this Form along with copies of the following to documents intertops. ag P. O. BOX W247 Wood s Centre St* John s Antigua Tel 1-268-480- 3100 documents intertops. ag 1 Passport or Drivers license of Intertops Accountholder both sides. 3 Authorized Credit Card s both sides. 4 Utility Bill bank statement or credit card statement Intertops Logon User Name or Customer Number Date Intertops Accountholder Name Accountholder Contact Telephone 1 By signing below I authorize the use of the following credit cards Authorized Card s for loading my Intertops account identified above. I also agree that I have been authorized to use all of the Authorized Card s listed below and agree to pay any and all charges incurred by these cards to fund my intentionally or inadvertently you shall be under no liability whatsoever including any fees imposed by my bank even though such dishonor may result in the inaccessibility of my Intertops account. By Signed Print Name CARD TYPE VISA DINERS CLUB CARD NUMBER EXPIRATION DATE MASTERCARD AMEX CARD BILLING ADDRESS if different than above CARDHOLDER S NAME as it appears on the credit card TODAY S DATE SIGNATURE OF CARDHOLDER Question Call 1-268-480-3100. ag P. O. BOX W247 Wood s Centre St* John s Antigua Tel 1-268-480- 3100 documents intertops. ag 1 Passport or Drivers license of Intertops Accountholder both sides. 3 Authorized Credit Card s both sides. 4 Utility Bill bank statement or credit card statement Intertops Logon User Name or Customer Number Date Intertops Accountholder Name Accountholder Contact Telephone 1 By signing below I authorize the use of the following credit cards Authorized Card s for loading my Intertops account identified above. 3 Authorized Credit Card s both sides. 4 Utility Bill bank statement or credit card statement Intertops Logon User Name or Customer Number Date Intertops Accountholder Name Accountholder Contact Telephone 1 By signing below I authorize the use of the following credit cards Authorized Card s for loading my Intertops account identified above. I also agree that I have been authorized to use all of the Authorized Card s listed below and agree to pay any and all charges incurred by these cards to fund my intentionally or inadvertently you shall be under no liability whatsoever including any fees imposed by my bank even though such dishonor may result in the inaccessibility of my Intertops account. I also agree that I have been authorized to use all of the Authorized Card s listed below and agree to pay any and all charges incurred by these cards to fund my intentionally or inadvertently you shall be under no liability whatsoever including any fees imposed by my bank even though such dishonor may result in the inaccessibility of my Intertops account. By Signed Print Name CARD TYPE VISA DINERS CLUB CARD NUMBER EXPIRATION DATE MASTERCARD AMEX CARD BILLING ADDRESS if different than above CARDHOLDER S NAME as it appears on the credit card TODAY S DATE SIGNATURE OF CARDHOLDER Question Call 1-268-480-3100. .

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