4691 Northwest Parkway, Hilliard Ohio 43026 Credit Card Authorization Form Card Holder Information   All Fields Are Required Company Name Taxpayer ID number Name on Card Card Holder Billing Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marinara Islands Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Telephone ( ) - - Email Payment Authorization Card Type Card Number Exp. Date 3 Digit Card Identification Number Print Name Date I hereby authorize the purchase of services/merchandise from Image One Cellular, LLC. using this Credit Card Authorization Form. I agree that I will pay for this purchase and indemnify and hold Image One Cellular harmless against any liability pursuant to this authorization. I understand that my signature on this form will serve as authorized signature on the credit card. I authorize Image One Cellular, LLC to charge the above provided credit card for any purchase of merchandise that resulted in my negligence to accept the shipment. I understand that I'm fully responsible for all charges of merchandise / services for which I have requested by phone or in writing from Image One Cellular, LLC.