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Credit Card Authorization Form

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Super Entertainment Inc

1644-20th Street, Santa Monica, CA 90404

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

AATIF  ASLAM  (IMPACT - 2010)

$39-$49-$59-$69-$79-VIP-VVIP

Add $15 S&H for UPS, if  mailed
 

I  (Name on the Credit Card)

 
  (First)

(Last)
 
residing at  
 

(Credit Card Billing Address)
 
City State

Zip

  
 
Phone

Fax

Email
 

(xxx-xxx-xxxx)

  

(xxx-xxx-xxxx)

  

(Personal or Company)
 
hereby authorize Super Entertainment Inc to charge US $:

for

  
 

(Total Amount)

  

(# of Tickets)
 
Valued at

Plus (S&H)

to my
  (Price per ticket)

 

(If Any)

  

(Choose Credit Card)
 
CC #: 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)
 
time

at

 

Special Notes, (if Any):

 
I undersign, hereby declare that the credit card information above is true, accurate to the best of my knowledge and appears in the name as stated. An Authorization is hereby 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 can not be refunded, replaced or exchanged, if lost, stolen, destroyed, misplaced or for any other reasons whatsoever.
 

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.
 
 

 
(Credit Card holder's Authorized Electronic Signature)  

 

    
 

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