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Credit Card Billing Information  

Account Number or Username:
If Unknown, leave Blank
        
First Name:   
Last Name:   
Address 1:   
Address 2:  Prov/State:  
City:  P.Code/Zip:  
Country: 
E-mail Address:  
 
Credit Card Information
 
Card Number: 
Card Type:     Exp. Date:  /  
Card Validation Code:  ( a 3 or 4 digit, non-embossed, printed on the front or the back of the Card) 
Issuing Bank: 
(Visa and MasterCard)
Charge Amount:
 
Please note: All personal and credit information submitted must be valid. For security purposes, any information submitted will be subject to verification. Any accounts with incorrect or invalid information will be disabled at our discretion.    

 

Terms and Conditions  
 
Sign below to confirm that you have read, understand and agree to the contents of the above paragraph. Your Electronic signature is assumed by your submission of this form.

__________________________________________________
Signature Date  

Email completed form to bonanza@comettele.com. Submit here

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