Credit Card Information and Authorization (Copy) — Winning Mind

Card Type

Visa, Mastercard or American Express

Cardholder Name

Please enter the name as it appears on the card

TAIS / Account Name (if applicable)

Credit Card Number

Please enter your card number

Expiration Date

Please enter the card expiration date

Card Identification Number

Please enter the 3 or 4 digit card security code

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Shipping Address (if different from Billing

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Please include a valid email address.

Contact Phone

Please include a good number to reach you on if we need to.

Country

(###)

###

####

Authorization

My initials below hereby authorize Winning Mind LLC to charge agreed upon TAIS and Consulting Related fees to the card indicated above. I will notify Winning Mind of any changes to my credit card information or of any desire on my part to change or terminate this authorization.

Note

Please let us know anything else important