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Credit Card Authorization Form – _Turn-Key_ Please print this page

VIEWS: 1 PAGES: 1

									                                         12200 E Briarwood Ave Ste 280               Centennial, CO 80112
                                                  www.insurance leads service.com
                                           Sales & Service: 720 979 8282 or 720 351 4656
                                                       Sales@ILS Email.com

                                    Credit Card Authorization Form – (Turn Key)
                            Please print this page, fill in the fields, and attach your signature.
                            Then return signed form to our office via fax at (303 790 7632)

Card Holder Name:                                               ______________________________________
Billing Address:                                                ______________________________________
City/State/Zip Code:                                            ______________________________________
Phone Number:                                                   ______________________________________
Fax Number:                                                     ______________________________________
Email:                                                          ______________________________________
County/Zip Codes Purchased:                                     ______________________________________
Monthly Tracking #:                                             YES         or       NO         (Tracks # of Phone Calls Received)
X Date (circle one Home Only):                                  30 days                  60 days
Number of Monthly Leads:                                        #HOME:____________#AUTO:___________
Credit Card Type (circle one):                                  Visa MasterCard AMEX Discover Other:____
Account Number:                                                 ______________________________________
Expiration Date:                                                ______________________________________
CID:                                                            ______________________________________
By my signature below, I agree to authorize, and do hereby authorize, ILS, Inc. dba (Insurance Leads Service) to charge to the above
indicated card an amount equal to the leads purchased each month ($0.22 per lead), plus the monthly software fee of $40.00 (Waived)
There is also a $12.95 Tracking Number Fee (Waived). I also agree to authorize, and do hereby authorize, Letters Plus (9940 E
Costilla Ave Ste U1, Englewood, CO 80112), to charge the above indicated card an amount equal to the leads purchased each month
(.43 per lead) for processing and postage services. Total Turn Key Cost (.65 cents per lead) for two page mailer.

This agreement is month to month and can be cancelled with 30 days written notice via email, fax, or USPS mail. All unpaid
accounts will be charged a 1.5% interest charge on the unpaid balance until the balance is paid in full along with any corresponding legal fees.

        INCLUDES: Custom Quote Template, Custom Cover Letter, Custom Window Envelope, Processing, Postage & Delivery to USPS.


Cardholder Signature:                                           ______________________________________

Date:                                                           ______________________________________

								
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