Super Cellular & Pager, Inc.

3030 Baseline Ave. Santa Ynez, CA 93460

1-800-898-1357; fx 805-686-2822

Credit Card Payment Authorization Form

Company Name: ___________________________________________________________________________

Card Holder Name (NAME AS IT APPEARS ON CARD) :

_________________________________________________________

Card Type: VISA____ Master Card ____

Billing Address (AS IT APPEARS ON YOUR CREDIT CARD STATEMENT) :

Telephone Number:________________________

Credit Card Number: ________________________________________________________________________

Expiration Date: ________/________/________ CVV Code: ________

I , ________________________ authorize Super Cellular & Pager, Inc. to charge my purchases on the above

referenced Credit Card. In choosing to use this card as a payment method, I guarantee that there will be no refund

or shipping charges (2way) in the event of a returned shipment due to refusal of delivery and a 10% restocking

fee for the refused good will apply if such happens. I also guarantee that no "charge back" will be issued, prior to

making contact with Super Cellular & Pager, Inc. to settle any disputes and acquiring written agreement to

perform a "charge back" to the above Credit Card for purchase.

Name (print please):___________________________________________________________________

Card Holder's Signature:________________________________________ Date:__________________

NOTE: ______________________________________________________________________________

Please send us this form via fax to 805-686-2822 or E-mail it to supercellularinc@yahoo.com

PLEASE READ THIS IMPORTANT INFORMATION:

IF YOU ARE E-MAILING THIS FORM PLEASE ATTACH YOUR I.D. AND CREDIT CARD PICTURE.

YOU MUST FOLLOW THE STEPS OF CREATING AN ELECTORNIC SIGNATURE

IF YOU ARE FAXING THIS FORM PLEASE ATTACH YOUR I.D. AND CREDIT CARD PICTURE. YOU

MUST MANUALLY SIGN THE FORM