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Credit Card Authorization Form

Ccomplete print and FAX TO 514-731-1909

I,  ___________________________________________________ hereby authorize

J White Publications Inc to charge my credit card.

Purchase of the 2012 Canadian Subsidy directory.

Type of Card      ð  Visa    ð  MasterCard  ð American Express

Credit Card Number:             __________________________________________

Expiration Date:                   __________________________________________

Name of Cardholder:            __________________________________________

Credit Card billing address:    __________________________________________

                                          __________________________________________

Total amount to be charged:  _______71.25__ (CAD) Canadian Dollars

Authorized Signature of Cardholder ______________________

Signing this, I acknowledge the charges described hereon and assume full responsibility for said charges and agree to honour and abide by the terms of payment.

Signature: __________________                         Date: ___________________
 

Mail orders by check or money orders.

Send your payment of $71.25 by check or money order payable and to

J White Publications Inc

CSP 24516 West Hill

Montreal QC H4B3A5