PAYMENTFORM NAME: _______________________________________________ PHONE: ______________________________________________ eMail : _________________________________________ (For eMail Receipt) The under signed here by authorizes RELINKco Inc. to Charge for the following as payment for services provided by RELINKco.
______$250.00 monthly (charged on 1st of the month)
_______$_________Enter Promo Code#_________
[ ] Visa [ ] MasterCard [ ] Discover [ ] American Express
Credit Card Number: _________-____________-_______-_________ Expiration Date: ______/_________CID/CVD#________(last3#backofcard) (Am Ex 4#Front top Right) Billing Address of Credit Card: ______________________________________ Card Holder Name: _______________________________________________ Card Holder Signature: __________________________________Date__________ Thank you. Your Credit Card Statement will show the processed amount as Checked from above through RELINKco Merchant Accounts. (*Reference WA DOL# _____________Start Date :________________) ADMIN RELINKco Inc.
After applying at DOL Licensing, Fax or call in Card Information Monday- Friday10- 5pmPacificTime
RELINKco 40 Lake Bellevue Suite 100 Bellevue WA 98005
