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Eminent Media Auto-Pay Form
Card Type:
*
Card Type:
Mastercard
VISA
Discover
AMEX
Other
Cardholder Name: (as shown on card):
Card Number:
*
*
Expiration Date (mm/yy)
*
*
Cardholder ZIP Code (from credit card billing address):
*
I authorize
Eminent Media
to charge my credit card above for agreed-upon purchases. I understand that my information will be saved to file for future transactions on my account.
$300 On The 26th Monthly
Signature
*
*
Submit