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(Name of the credit card holder) |
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residing at: |
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City |
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(First) |
(Last) |
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(Credit Card Billing Address) |
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| State: |
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Zip: |
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Country: |
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| D/L #: |
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D/L State: |
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D/L
Exp Dt: |
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(Driver Licence #) |
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(Driver Licence State) |
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dd/mm/yyyy |
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| Phone Hm: |
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Phone Off: |
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E-mail: |
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(Required)
xxx-xxx-xxxx |
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(If Available)
xxx-xxx-xxxx |
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(Required) |
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hereby authorize Super Entertainment Inc. to charge US
$: |
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for: |
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(Total Amount) |
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(# of Tickets) |
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| valued at: |
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plus (S&H): |
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to my: |
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(Price per Ticket) |
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(Choose One) |
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C/C No: |
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CVV #: |
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expiring on: |
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(Credit Card Number) |
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(Click here for info) |
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mm/yy |
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| for purchase of the
tickets, for the show: |
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to be held on: |
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(Name of the Show) |
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(MM/DD/YYYY) |
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at: |
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time: |
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(Venue) |
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| Special notes (if any). |
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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. |
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Type in your name on
the left and click
I Agree
button below. |
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Credit Card holder's Authorized Electronic Signature |
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Date |
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