Creative Hair Designs By Chance  Charge Slip                                     

Billing Information

Charge Amount:

Card Type:

Credit Card Number:

Expiration Date:    

First Name:  (as it appears on card)

Last Name: (as it appears on card)

Billing Address:

Billing Address 2:

Cit y:

State:

Zip Code:

Email:

Home Telephone:

Is billing address above also your credit card billing address?
Yes     No  
(your billing address must match your credit card address)

A confirmation will be emailed to you shortly after charge is accepted. The charge will read from PayPal (chanceirby@cs.com)

I authorize PayPal (Chance Irby) to charge my credit card account in the amount stated above. By clicking submit, I am digitally signing this authorization form.