CREDIT CARD PRE-AUTHORIZATION FORM

CREDIT CARDHOLDER INFORMATION

NAME ON CREDIT CARD Ambreen Mumtaz

TYPE OF CREDIT CARD  VISA  MC

TYPE OF ACCOUNT  PERSONAL  BUSINESS

ACCOUNT NUMBER
EXPIRATION DATE
CVV (3 digit number on
back of Visa/MC)
(Optional)
BILLING ADDRESS
CITY PROVINCE POSTAL CODE
PHONE FAX NUMBER
(Optional) (Optional)
EMAIL (Optional)

AUTHORIZATION OF CARD USE

I certify that all information above is complete and accurate.

I certify that I am the authorized holder and signer of the credit card referenced above and that I will not dispute
the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this
form.

I hereby authorize IVC Telecom Inc. to charge my credit card indicated in this authorization form above. This
authorization from is for the goods/services described on the IVC Telecom Inc. invoice for monthly regular
recurring payment(s) and/or one-time payment(s) from time to time, for payment of all charges arising under my
IVC Telecom Inc. account(s).

CARDHOLDER NAME
(Print)
SIGNATURE DATE

IVC Telecom Inc.

867 Boulevard Décarie #101
Saint-Laurent, QC H4L 3M2
Phone: (514) 876-0900
www.ivctel.com