SEI

Super Entertainment Inc.  

1644-20th Street, Santa Monica, CA 90404

Tel: 310-829-2985  *  Fax: 310-828-3876

 

CREDIT CARD AUTHORIZATION FORM for SUMMER BEATS 2008

Add $ 15.00 Shipping Charges for UPS if you want the tickets to be mailed.

 
 
I  (Name of the credit card holder)  

 

residing at:   City

 

  (First)

(Last)

  (Credit Card Billing Address)    
           
State:   Zip:   Country:

           
D/L #:   D/L State:   D/L Exp Dt:

 

  (Driver Licence #)   (Driver Licence State)  

dd/mm/yyyy

           
Phone Hm:   Phone Off: E-mail:

  (Required) xxx-xxx-xxxx   (If Available) xxx-xxx-xxxx  

(Required)

           

hereby authorize Super Entertainment Inc. to charge US $:

  for:

 

      (Total Amount)  

(# of Tickets)

           
valued at:   plus (S&H): to my:

 

  (Price per Ticket)      

(Choose One)

           
C/C No:   CVV #:   expiring on:

 

  (Credit Card Number)   (Click here for info)  

mm/yy

           
for purchase of the tickets, for the show:   to be held on:

 

     

(Name of the Show)

 

(MM/DD/YYYY)

           
at:       time:

 

  (Venue)        
           
Special notes (if any).
           

I, undersign, hereby declare that the credit card information above is true, accurate and appears in the name as stated and authorization is given to the above named individuals to use this card for purchases. Further I authorize my Credit Card company to accept and to charge my account purchases from Super Entertainment Inc. on my card as mentioned above.  I also understand that all sales are final and once the Tickets are purchased by me, it cannot be refunded, replaced or exchanged, if lost, stolen, destroyed, misplaced or for any other reasons whatsoever.

           

 

Type in your name on the left and click I Agree button below.

 

Credit Card holder's Authorized Electronic Signature     Date
           
       

Make sure all fields are filled in, before submitting it by clicking on the I Agree tab above.

By clicking I Agree, you Agree to the terms and conditions mentioned above and authorize SEI to proceed with the transaction.

 

(FOR OFFICE USE ONLY)

 
Authorization #:       Date:  
           

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