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As you probably know, fraudulent credit card use is at an all time high. As a result, we now require you to fill out this form to prove that the card you are using belongs to you that you are over 18 years of age. We apologize for the inconvenience but this is for your protection as well as ours. WE WILL NOT PLACE ANY CHARGES TO YOUR ACCOUNT UNLESS REQUESTED BY YOU! This form is held in strict confidence. We do not release any personal information to anyone for any reason! For security reasons we do not enter your card number in our computers; this form is kept on file. Please include your daytime phone below in case there is a problem. We will not call you unless we have to, and we will be discreet if we do. If you have any questions, feel free to call us at 1-800-716-7705. Thank you for your cooperation. I, ___________________________________________ hereby acknowledge and grant JB Video permission to process any orders from this day forth that I may make at my own discretion using my credit card; Furthermore, I certify that I am a resident of the city and state indicated on this form and that I am an adult under the laws of that jurisdiction regulating dissemination of sexually oriented materials to minors. I further acknowledge that any commercial exhibition of them would violate the copyright interests of JB Video. I am familiar with the community standards of the community where I reside and to which the materials which I am ordering will be shipped and I certify that nothing which I am ordering involves depictions which are unacceptable according to the standards of the average adult in my community.This form represents a valid credit card authorization form in the event of a credit card dispute for any charges, past or present, that I may make with your company.
SIGNATURE ____________________________________________ DATE ___________ |
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CARD NUMBER ____________-____________-____________-____________ CCV EXTENSION ____________ (three extra numbers on the back of your card - click here for help) BILLING ADDRESS (how your address appears on your credit card statement)
___________________________________________ ___________________________________________ MAILING ADDRESS (if different)
____________________________________________ ____________________________________________ CUSTOMER SERVICE PHONE (______) _________________________ (on back of credit card) YOUR DAYTIME PHONE (______) __________________________________
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