NJ Media Group, LLC.

NJ Marketeer.com
11 Melanie Lane, Unit #4 • East Hanover, NJ 07936
Phone: 973.434.8888• Fax: 973.434.8765

Client Credit Card Authorization Form

I hereby authorize NJ Community Publishing to charge any monies owed on my account for advertising services
to the following credit card:

ADVERTISER NAME:

NAME (as it appears on credit card):

BILLING ADDRESS:

TYPE OF CARD:

CARD NUMBER & 3 or 4 DIGIT V-NUMBER:

EXPIRATION DATE:

AMOUNT AUTHORIZED: $

CLIENT AUTHORIZATION SIGNATURE:

DATE:

PLEASE SIGN AND FAX THIS PAGE TO (973) 434.8765. THANK YOU FOR YOUR BUSINESS.

FOR OFFICE USE ONLY – DO NOT WRITE BELOW THIS LINE:

AUTHORIZATION NUMBER: _________________________________________

AUTHORIZATION DATE: _________________________________________

SALES REP: _________________________________________

Credit Card Authorization Form rev. 8/29/08