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In connection with my purchase
of PeopleFinder product(s) from Pallorium, Inc., I hereby authorize
Pallorium, Inc. to charge the below specified credit card the
amount of:
Amount of Charge: $_______________________________________________________________________
(print or type the EXACT AMOUNT you authorize us to charge your
credit card)
_____________________
Name of Cardholder:
______________________________________________________________________
(print or type YOUR COMPLETE NAME exactly as it appears on your
credit card)
Residing at or Doing
Business at: ____________________________________________________________
(print or type the BILLING ADDRESS of your credit card)
Telephone Number: _______________________________________________________________________
(print or type your DAYTIME TELEPHONE NUMBER)
Credit Card Number:
______________________________________________________________________
(print or type the complete NUMBER of YOUR CREDIT CARD)
Expiration Date of
Credit Card: _______/_______/20_____
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_________________________________________,
_______/________/20_____ (Cardholder signature and today's
date here)
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I understand that there
are no refunds, returns or exchanges of any kind.
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Please fax your completed
and signed Credit Card Charge Authorization form to Pallorium,
Inc., at: 212-858-5720.
PLEASE REMEMBER TO
ALSO RETURN YOUR COMPLETED "PEOPLEFINDER
ORDER FORM" WITH
THIS PAGE.
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Thank you for allowing Pallorium, Inc. to assist
you with your investigative requirements.
Pallorium, Inc. accepts American Express, Mastercard,
Visa, Diners Club and Discover.
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