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Credit_Card_Payment_Form_5-1-12

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					                                        ANNOUNCES “NEW”
EASY, NO FUSS, NO BOTHER, NO LATE CHARGES PAYMENT PLAN. HAVE
YOUR PAYMENTS DEDUCTED AUTOMATICALLY FROM YOUR CHECK
CARD OR CHARGE CARD. WE NOW ACCEPT M/C, VISA, OR DISCOVER.
NAME____________________________________ CIRCLE ONE M/C, VISA,DISCOVER

CC MAILING ADDRESS________________________3 DIGIT CODE____________

CARD #_______________________________________EXP.________________

E-MAIL___________________________________________________________
                          (PLEASE PRINT CLEARLY – THIS WILL BE FOR YOUR RECEIPT EACH MONTH)


PLEASE CHECK THE PAYMENT PLAN YOU DESIRE AND RETURN IMMEDIATELY FOR SETUP:

    1. PLEASE SIGN ME UP FOR THE MONTHLY PAYMENT PLAN________________

        (PAYMENT DEDUCTED ON THE 1ST OF EACH MONTH)

    2. PLEASE SIGN ME UP FOR THE 1 TIME COSTUME PAYMENT PLAN__________

        (PAYMENT DEDUCTED ON DUE DATE NOVEMBER 20, 2012)

    3. PLEASE SIGN ME UP FOR THE 1 TIME ACCESSORY PAYMENT PLAN ________

        (PAYMENT DEDUCTED ON DUE DATE JANUARY 1ST, 2013)
                    IF YOU HAVE ANY QUESTIONS, PLEAS E CALL ME AT 203 888-0763. THANK YOU, RITA

I authorize Rita Tottenham Studios to keep my signature-on-file beginning on ___________________________and
ending on 6/30/13, and to charge my credit/check card for the balance of charges related to all transactions during
that time as stated above. Signature____________________________________Date________________________

                                                                                                        Rev-5-1-12

				
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