| CREDIT PURCHASE AUTHORIZATION / MONIES ISSUANCE FORM |
| Please Complete and Fax to: 416-644-0139 |
| Important: You must include a photocopy of your credit card(s) and Valid Drivers License or Passport. Make sure your photocopy is readable. We recommend enlarging to 120%. |
| TELEPHONE DEPOSITS
I,
do hereby certify and attest that I am the authorized cardholder for the
below listed credit card(s) and agree to pay for the E-Cash purchased
under the captioned Electronic Financial Services (EFS) account using the
credit card(s) indicated below. I confirm that I have used the services of
EFS (Credit Card Processor and
Gateway Financial Services Ltd
(Merchant Account), and agree to pay the below listed amount.
Please Select (check one or both): I do hereby authorize Gateway Financial Services Ltd to charge my credit card and deposit funds into my EFS account for the amount listed below. |
| Credit Card Number | Expiration Date | Payment |
|
I do hereby authorize
Gateway Financial Services Ltd to
charge my credit card(s) in each instance that I verbally authorize a
deposit to my EFS account over their recorded telephone lines. |
| Credit Card Number(s)* | Expiration Date |
| * Your credit card(s) will be charged per your verbal instructions in the exact order that they are listed. |
Authorized Signature ____________________________________ Date________________
| INTERNET / ONLINE DEPOSITS
I
,
acknowledge that he maximum amount of E-CASH that I can purchase for my
EFS account is currently US$1,000 per day, and I do herby request and
authorize EFS and Gateway
Financial Services Ltd to increase
my maximum online deposit amount to US$10,000 per month. I will take every
precaution necessary to ensure the security of both my USERNAME and
PASSWORD and will take full responsibility for all charges posted to my
EFS account in the event of fraud.
|
| Credit Card Number | Expiration Date |
Authorized Signature ____________________________________ Date________________