CARD AUTHORIZATION

AXIS TOPIA LLC

1 844 258 0301

Info@rasine.org

1401 Pennsylvania Ave STE 105 Wilmington, 19806

Credit/Debit Card Authorization Form

I acknowledge that AXIS TOPIA LLC is authorized to charge my credit/debit card for the service as listed below.

Card Information

Amount to be charged $

Credit/ Debit card Number

Expiration Date

SVC Code

Card Holder Information As It Appears On Your Account

First name

Last name

Full Address

I give my permission for AXIS TOPIA LLC to charge the card for the amount listed above. I understand that the terms of this authorization will remain valid until the full payment is fulfilled. I acknowledge my responsibility for this transaction by printing and signing this form.

Cardholder Signature

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Date and time

Month

Day

Year

Time

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