Credit/Debit Form

Use this form to submit your credit/debit card information

CONTACT INFORMATION

Company/Organization *

Your Name *

Email Address *

Phone Number *



Authorization Statement
I authorize ChristianNetcast.com to initiate either an electronic debit or to create and process a demand draft against my bank account according to the terms outlined below. I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law.

Terms of Billing
Account will be debited on/after the 1st of each month for the total amount owed to merchant.

CARD INFORMATION

Card Type *

Card Number *

Expiration Date (MM/YYYY) *

Security Code on Back of Card *

Name Printed on Card *



CARD BILLING ADDRESS

Street Address *

City *

State *

Zip Code *



Comments



By clicking "Send", you confirm that your card will automatically be charged, on or after the 1st of each month, for the balance due on your account.