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Client Payment Authorization Form

Please fill out your billing details below. You can securely send this information by selecting the "Submit" button below or by printing and faxing to: 1-906-661-2040

Auto Debit

Note: Please use this option for all recurring campaigns. We will never bill you more than our agreed upon price.

I hereby authorize eComp
Marketing LLC to bill my:(*)
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** OR **

One-Time Debit

Note: Please use this option for all non-recurring, single payment orders.

in the amount of:(*)
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on or after:(*)
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Credit/Debit Card Details

Credit/Debit/Check Card Number(*)
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Expiration Date:(*)
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This Card Is A:(*)
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Signature:(*)
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Printed Name as it
Appears on Card:(*)
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Company Name:(*)
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CCV Code (3 or 4
digit security code
back of the card):(*)
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Note: For security and authentication purposes, we require the account holder to provide the address to which the credit card statements are sent.

Street Address:(*)
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Address Line2:(*)
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City(*)
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State:
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Zip Code:
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Country:
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Phone:(*)
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eMail Address:(*)
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Local Details

eComp Marketing LLC ®
1237 Anthony Street
Hancock, MI 49930
Phone: 906-661-2226

Newsletter Signup

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First Name(*)
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Last Name
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E-mail(*)
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Captcha(*) Captcha
Refresh
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https://www.ecompmarketing.com/index.php?option=com_rsform&view=rsform&formId=10