CC | Glick + Fray

Contact Information
Company Name
First Last
Check only one:*
- As the Individual cardholder, I hereby authorize this card to be used for the payment/deposit required.
- As the company representative, I hereby authorize this card to be used for the payment/deposit required.
Cardholder Information
Type of card:*
- Visa*
- Mastercard*
- American Express*
*Please note: postage credit card payment are subject to a 5% handling fee. *Credit card payments for jobs are subject to a 3% pass through fee.
Credit Card Number*
NOTE This field is secure and encrypted
Expiration Date*
MM slash DD slash YYYY
Security code:*
Visa/Mastercard (3 digits on back), American Express (4 digits on front) This field is encrypted
Name as it appears on the card*
First Middle Last
Credit Card Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Deposits/Payments*
I hereby authorize this card to be used for the future deposits and/or final payment.
Terms and Conditions
1. OUTSIDE PURCHASE Unless otherwise agreed in writing, all outside purchases (i.e. hosting and printing services.)as requested or authorized by the customer, are chargeable. 2. RECURRING CHARGES Hosting charges and other monthly fees and retainers are chargeable unless otherwise agreed upon.
Terms and Conditions Agreement*
I have read and agree to the terms and conditions listed above.
Authorization Signature*
Please type your full name. Typed name serves as signature.
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Contact Information