Credit Card Form

CARD HOLDER INFORMATION

CUSTOMER NAME:

NAME ON CARD:

CARD HOLDER BILLING ADDRESS:

PAYMENT AUTHORIZATION

CARD TYPE:

CARD NUMBER:

CCD NUMBER:

EXPIRATION DATE:

As the authorized holder of the above referenced credit card, the below signed hereby authorizes payment to PPL Labs LLC for the services and deliverables provided to the above referenced Company. The below signed further acknowledges that certain services and deliverables provided by PPL Labs LLC require recurring periodic payments as outlined in the Purchase Order and that this Purchase Order and Credit Card Authorization Form shall serve as the standing authorization with regard to such future payment obligations.

Authorized Signatory

NAME:

DATE
Please leave this field empty.