ACKNOWLEDGEMENT OF CARD BILLING

I, …………………………………………………, Have authorized the "( Merchant )"

" CISE ELECTRONICS CORPORATION " , to charge my ……………in the

amount of……………………………………………………………………………....................

$ …………….US dollars, for goods and / or services specifically descripted

as : ………..................………………..………………………………………………………………

………………......................…………………………………………………………………………….


My card number is:…...…..............…………………………………………..……....…

Exp. Date ( MM/YY) ……/…….

CVV2/CVC2/CID number:.................

My name as it appears on my card is ...............………………………………..……

The billing address for my card is:....................................................

...................................................................................................

State/Province...........................Country..........................................

Phone:......................................

Sign Here…….......……………….........Date …………………….……………..…..... 2015.
               (Cardholder)

Send by Fax to: Cise Electronics Corp.
Fax number: 786 293 1076

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