Celebration D. J., LLC
P. O. Box 14002
Kansas City, MO 64152
Phone: (816) 808-9325      E-Mail: DJLASHA@AOL.com
www.djlasha.com

Charge Card Authorization

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Address __________________________

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Method of Payment is Check #_____________

Master Card [   ]                         Visa [   ]                      American Express [  ]

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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__________________________
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