ZipX Curaçao ~ Authorization Form for Credit Cards

Box Information
P.O. Box/ZipX Number/ Department Code:
Name:
Address:
Town/District/Postal Code:
Phone:
Fax:
Cell:
E-Mail:
Business Phone:
Business Fax:

Credit Card Information
Type of Credit Card:
Card Number:
Bank:
Expiration Date:

I hereby authorize the accounts receivable department of IBC Express N.V. in Curaçao to deduct all monthly ZipX, Quarterly P.O. Box, and annual membership charges from my credit card.

By submitting this form, you acknowledge that you have read, understood, and agree to accept the Terms and Conditions of this agreement.