CREDIT CARD AUTHORIZATION FORM
DATE STATION ADVERTISER ACCT EXEC AGENCY
CLEAR CHANNEL CINCINNATI
I,
(PRINTED NAME OF CLIENT / CARD HOLDER)
HEREBY AUTHORIZE CLEAR
CHANNEL WORLDWIDE (CINCINNATI) TO CHARGE MY CREDIT CARD AS FOLLOWS: TOTAL SCHEDULE
OR
CONTRACT NUMBER START DATE / END DATE
$ INVOICE # INVOICE # INVOICE # INVOICE # AMERICAN EXPRESS
PLEASE WRITE CARD NUMBER ABOVE
FOR INVOICE NUMBER(S)
$ $ $ $
VISA
MASTERCARD
EXPIRATION DATE BILLING ADDRESS FOR CARD
AUTHORIZED SIGNATURE
TELEPHONE NUMBER COMMENTS:
FAX NUMBER
PLEASE NOTE: THIS COMPLETED FORM MUST BE ACCOMPANIED BY A PHOTOCOPY OF THE CREDIT CARD (FRONT AND BACK)
DATE PROCESSED APPROVAL NUMBER PROCESSED BY
BUSINESS OFFICE USAGE ONLY