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Credit Card Authorization
By completing this secured form, you authorize American Ventures, Inc., D/B/A Advanced Insurance Services to make a one-time charge in the amount indicated below.
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Your Company Name
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If you are making a payment for your company, please list the name of your company here. If you do not have a company name just put a "-" dash.
Name on Card
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First
Last
Contact Phone Number
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Email
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Amount of Charge
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If you are making a down payment enter that amount from the information you received or if you are making payment in full, enter that amount.
Credit Card Number
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Expiration Date
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Security Code (CVV)
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This is the three digit security code on the back of MC, Visa and Discover Cards and the four digit on the front right of the AMX cards.
No coverage is in effect
until you receive written proof of coverage from an insurance company. The acceptance of payment from you by Advanced Insurance Services does not constitute coverage. We accept your payment as a method of facilitating the process of obtaining coverage.
Comment
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Notate any special instructions you want in this section. Such as certificate reproduction, down payment, etc.
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