Influence Direct, Inc.

Mail Payment Authorization - Credit Card

CREDIT CARD AUTHORIZATION:  I/We (“Client”) hereby authorize Influence Direct, Inc. to debit my/our credit card for the amount indicated below. By completing this form and signing below, you acknowledge approval for a credit card debit to your account for our services. Charges will appear from Influence Direct, In. on your statement. Thank you for selecting Influence Direct, Inc.

Card Type:
  Credit Card Number:  

Expiration Date:   CVV:

Cardholder Name:   Billing Address:

Billing City:   Billing State:   Billing Zip:

I/We authorize Influence Direct, Inc. to charge my/our credit card the total amount of: $  for Invoice(s) #  


By signing below, you (Client) agree to remit full payment for your Project to Influence Direct, Inc. You also agree that the proofs are correct as ordered. Influence Direct, Inc. assumes no liability for the results of your mailing campaign. A completed order for a Project consists of an authorized invoice, signed proofs, data and payment. Influence Direct, Inc. cannot guarantee specific drop dates of your mail campaign, when/if any inbound calls begin and delivery time frames of the United States Postal Service.  You also agree that the Project services for which payment is provided herewith are subject to all terms and conditions contained in the Contract for Services between Influence Direct, Inc. and Client.


Customer Name:  

Print Authorized Name:  


Leave this empty:

Influence Direct, Inc.
Signature Certificate
Document name: Mail Payment Authorization - Credit Card
Unique Document ID: c6ff3a9335fd233652d60449e079e48d7eb5807c
Timestamp Audit
2016-04-21 19:02:20 CDTMail Payment Authorization - Credit Card Uploaded by Jeremy Crosslin - IP