Company Name:
Type of Card: VISA MASTERCARD AMERICAN EXPRESS
Card Number: --- Expiry Date (Month/Year): /
Cardholder’s Name (as it appears on card):
Bank:
Billing Address for card (where your statement is sent):
Street Address:
City: Prov/State:
Postal Code:
Voice Phone: Fax Phone:
I hereby knowingly and irrevocably authorize Sixth Sense Software Company Inc. to charge purchases made from Sixth Sense Software Company Inc. to the above credit card. The credit card account information provided herein shall be used only for the intended purpose as authorized. Cardholder shall indemnify and hold Sixth Sense Software Company Inc. harmless from all loss, damages, expense or liability in connection with such authorized use of the above said credit card. Any use by Sixth Sense Software Company Inc. is limited to the sale of merchandise and support services to the Cardholder. All information disclosed herein is true and correct, without exception. In the event the information disclosed in the credit card authorization form is in any way incorrect, false or fraudulent, the cardholder shall be liable for all costs, expenses and attorney fees incurred in protecting Sixth Sense Software Company Inc.’s rights and interests. Sixth Sense Software Company Inc. shall not be liable to the cardholder for any incidental, consequential, special or punitive damages arising out of this authorization. I hereby authorize and consent to the collection, use and release of any credit, personal or other information about me at any time, from, to or with any credit bureau, reporting agency, or credit grantor. I understand that all such information shall be collected and used by Sixth Sense Software Company Inc., its affiliates and service providers and their respective successors and assigns for assessing my credit-worthiness in connection with this authorization and application for credit.
Signature: ___________________________________________(as it appears on the card)
Name: Date (Day/Month/Year): //