Credit Card Authorization Form

Studio _________________________________________________________________________________

Card Holders Name: _____________________________________________________________________

(Please print as it appears on the card)

Billing Address: _________________________________________________________________________

______________________________________________________________________________________________________________________________________________________

Telephone Number: (_________) _________________Cell (_____) ____________________________

Credit Card Type (Check One)

______American Express                                           ______MasterCard                                         ______Visa    

Credit Card Number: ____________________________________________________________________

Expiration Date: ________________________________ 3 or 4 digit code from back of card ___________

Statement of Cardholder:

I hear by authorize Star Systems Talent to charge my above referenced credit card for competition fees for:

____________________________________ City Attending                     _____________ Amount

Other Conditions (If Any): _________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

Signature of Card Holder: __________________________________ Date: _________________________

A legible copy of the credit card being used (front & back) must be submitted with this form and faxed to 336-993-9075 fax.