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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 (M.D.Y):
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Credit/Debit Card Details
Credit/Debit/Check Card Number*
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Expiration Date (M.D.Y):*
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Card Type:*
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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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Street Address 2:*
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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:*
Please enter a valid email address

Print form to manually fax if desired.

Local Details

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

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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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