Credit Card and other Payment Information
RSVP PAYMENT FORM Latin Times Representative : ____________________________
Company Name : ____________________ Title : ____________________
Package Name : ___________________________ Contact Name ________________________
Credit Card and other Payment Information
Check Payments Mail to : Latin Times Media , Inc ., P . O . Box 15312 , Brooksville , FL . 34604 Attn : Victor Padilla , Email Jolie @ Latin-Times . com or Fax completed forms to : ( 813 ) 489-2422
• CREDIT CARD INFORMATION
• Name as it appears on Credit Card : ______________________________ Type of Card : ________ Amount Paid : $____________
• Credit Card number : ___________________________________ Exp Date : _____________ Security code on back of card : __________
• Billing address of Card :______________________________ City : ____________________ State : __________ Zip Code : ____________
WANT TO PAY BY E-CHECK PAYMENT INFORMATION ( ACH TRANSACTION )
• Bank Name :__________________________ Name on Bank Account :______________________ Routing Number :______________________ Account Number :___________________________
• E-Mail Address for your receipt ( Must be your official email address ): ________________________________
By signing this form , you are authorizing Latin Times Media Inc ., Hispanic Resource Foundation , Inc ., and it ’ s subsidiaries to debit your credit / debit card or Checking account for all services provided to you and for all open balances owed to participate as a client of Latin Times Media , Inc ., Your marketing package is described above . Terms : Once Payment is received , your marketing and promotional package begins . Please note Bank Account with transaction details . There are NO REFUNDS on any Payments or Deposits . All Balances paid by credit card are charged a processing fee of 3.99 %. This includes package , which has been pre-purchased and reserved for you , promotion of your business begins immediately upon receipt of this Application / Agreement form . This media service offers limited exclusivity opportunities and by paying / Securing this space , you may also be preventing others with a like business from securing . This Agreement does not imply nor guarantee any exclusivity as to the selling services or products approved by the Latin Times Media , Inc .. I understand there are NO REFUNDS on payments or deposits . If this charge is contested and we receive a notification of Charge Back or NSF during a later date you will be subject to all Court , Legal , and / or collection fees .
• Authorization Signature : ________________________________ Date : _____________________