MFN FAX Form

PLEASE RETURN THIS FORM TO 601.948.6710

Mississippi Food Network
Automatic Credit Card Billing Authorization Form

To process your credit card payment, please complete the Credit Card Information section below and sign the form. All requested information is required. Upon approval, we will automatically bill your credit card for the amount indicated and your total charges will appear on your monthly credit card statement.

Credit Card Information

Name:___________________________________

Address: ________________________________
________________________________________
________________________________________

Payment Information
I authorize Mississippi Food Network to bill the card listed below as specified:

Amount to be billed: ____________________________ (this is not a recurring charge)



Credit Card Information (To be completed by customer)

The Mississippi Food Network accepts the following credit cards: Visa, MasterCard

Credit card type: ____________________

Credit card number: _______________________________Expires: ______________________

Cardholder's name: _____________________________________________

Cardholder's Zip code (required): ________________ (as shown on credit card from credit card billing address)

Your phone number:  __________________________________________________

Customer's signature: ___________________________________________________

Date: _________________________