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Ripco Communications, Inc. Credit Card Authorization Request

Fax to:773-477-2990  
Mail to:Ripco Communications, Inc. 3163 N. Clybourn, Chicago, IL 60618

This request is made to Ripco Communications, Inc. (“Ripco”) to charge
the credit card indicated below for services provided by Ripco 
Communications to the undersigned cardholder.  Signing this request 
indicates the cardholders agreement: 

- To provide true, accurate and complete information and to notify 
Ripco of changes or updates to your account information.* 
- To not impersonate any other person or use a name that you are not 
authorized to use. 
- That the cardholder below is the same person that Ripco is providing
services to and who has signed the Ripco Account Application and 
indicated agreement to Ripco’s Acceptable Use Policy.

NOTE:  If any information provided below or on Ripco’s Account 
Application is untrue, inaccurate, not current, or incomplete, without 
limiting other remedies, Ripco has the right to terminate use of 
the Ripco-provided services and entitle Ripco to recover from the 
undersigned any costs or losses incurred as a direct or indirect 
result of the inaccurate or incomplete information.   The undersigned 
cardholder authorizes Ripco, directly or through third parties, 
to make any inquiries we consider necessary to validate the 
cardholders information.  Ripco will not disclose the information 
provided below for purposes other than validation.

Following information must be as it appears on your Credit Card Account

First Name
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Last Name
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Credit Card Type/Number	Circle One: Visa   MC   Amex   Discover

Credit Card Number:
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Expiration mm/yy     
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Credit Card Verification Number(3-digits)
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Address Line 1
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Address Line 2
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City	
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State	
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Zip Code	
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Telephone Number	
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E-mail*	
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Account Name	
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Amount to Charge	$
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Frequency-Circle one:Once  Monthly  Quarterly  Semi-Annually  Annually

Start Date for Billing * mm/dd/yy
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*For recurring billing only 

I authorize Ripco Communications, Inc. to charge the credit card listed
above for the amount(s) indicated above as payment for Ripco-provided 
services.


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Signature							Date

REQUEST TO TERMINATE AUTHORIZATION OF RECURRING PAYMENTS MUST BE MADE IN 
WRITING, 30 DAYS PRIOR TO THE NEXT SCHEDULED PAYMENT, TO:

Ripco Communications, Inc.
3163 N. Clybourn
Chicago, IL  60618
Questions?  Call 773-528-5020 or email: billing@ripco.com