Serges & Company, inc.

Letter of Intent for Credit Card Purchase

Due to the risk of credit and mail fraud, we request a signed "letter of intent" for all credit card purchases. Please print out this page, complete it, and fax it to us. Credit card transactions will be processed  ONLY after receiving a signed letter of intent and all items are verified.  If you are not comfortable providing the necessary information in this manor, please contact us to discuss other payment options.

I, ___________________________ give my full authorization to / Serges & Company, inc. to charge my _______________ card for the following goods/services:

The total amount of this transaction is $_____________ US dollars
My name appears on the card as  __________________________
Complete billing address _________________________________
My phone number _______________________________________
My card number _______________________________________
Card expiration ________________________________________
The bank the card is issued on _____________________________
The issuing bank phone number (if possible)___________________

I understand and agree that / Serges & Company, inc.
has the right to verify this information.

Card holder signature_________________________
Today's date _______________________________

Please print, completely fill out and fax this page to 954-583-6559