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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