Fax To Email Credit Card Authorization Form

Please fill out and fax to 732-559-8900
or
Call us Toll Free at 800 321 1577 x201

Date:
Name: Billing Address City, ST Zip
Credit Card Type:
Credit Card #:
Expiration Date
Card Verification Code (for Visa/MC above signature on back of card
Billing Zip Code:
Phone Number of Card Holder

Standard Package - $25 set up $199 per year – includes 50 pages per month 10 cents each additional page	Silver Package – No Set Up $399 per year – includes 400 pages per month 9 cents each additional page
Gold Package $699 per year - includes 800 pages per month 8 cents per additional page.

I understand that Launchfax does not offer refunds

Email address to send faxes to __________________________________________________

Signature of Card Holder: Cardholder phone #

____________________________ ____________________________

Please return via fax – 732-559-8900