Credit Card Authorization Form
Super Entertainment Inc
1644-20th Street, Santa Monica, CA 90404
Tel: 310-829-2985 * Fax: 310-828-3876
PARESH RAWAL - KRISHAN VS KANHAIYA
$29-$39-$49-$59-$69-VIP($79)
Add $15 S&H for UPS, if mailed
I (Name on the Credit Card)
(Last)
(Credit Card Billing Address)
Zip
Fax
Email
(xxx-xxx-xxxx)
(Personal or Company)
for
(Total Amount)
(# of Tickets)
Plus (S&H)
$15 (UPS)
to my
(If Any)
(Choose Credit Card)
expiring on
(mm/yy)
to be held on
Sep 18th, 2010
(Name of the Show)
(mm/dd/yyyy)
at
La Mirada Theatre, La Mirada
Special Notes, (if Any):
Type in your first and last name below. Enter the month, date and year and then click I Agree button below to authorize chrges. Make sure all fields are filled in before submitting. By clicking on I Agree tab below you agree to the terms and conditions mentioned above and authorize Super Entertainment Inc to proceed with the transaction.
Month January February March April May June July August September October November December
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