Cin.Net 721 West Golf Road Hoffman Estates, IL 60194 Phone: (847) 310-1188 Fax: 847-885-8308 http://www.cin.net

Credit Card Authorization

Customer Information

Last Name

First Name

Middle

Present Address

City

State

Zip

Time at this Address

Home Phone Number

Work Phone Number

Fax Number

Email address

Drivers License No.

State Issued

Date of Birth

Social Security #

Credit Card Information

Card Type Visa Mastercard

Discover American Express

Expiration Date

Account Number

Credit Card Holder Name (As It Appears On the Card)

Billing Address

City

State

Zip

I state that all information forth mentioned is true. I authorize the company Cin.Net, also known as Computerese Information Network, Inc., to charge the above credit card account for Cin.Net services.
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