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Celebration D. J., LLC P. O. Box 14002 Kansas City, MO 64152 Phone: (816) 520-6227 E-Mail: DJLASHA@AOL.com www.djlasha.com 4040vision Charge Card Authorization
Name ________________________ Phone ______________________
Address __________________________
__________________________
Method of Payment is Check #_____________
Master Card [ ] Visa [ ] American Express [ ]
Card # __ __ __ __ __ __ __ __ __
Expiration Date: ___________________
Name Printed On Card___________________________________________
Billing Address ________________________________________________
Verification Code (Last 3 numbers on back of card near signature)________
Amount Of Payment $_____________ For:__________________________
Authorized Signature __________________________________
Print Name Of Above Signature__________________________ Thank You!
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