Credit Card and other Payment Information
RSVP PAYMENT FORM Latin Times Representative: ____________________________
Company Name: ____________________ Title: ____________________
Package Name: ___________________________ Contact Name ________________________
Credit Card and other Payment Information
Check Payments Mail to: Latin Times Media, Inc., P. O. Box 15312, Brooksville, FL. 34604 Attn: Victor Padilla, Email Jolie @ Latin-Times. com or Fax completed forms to:( 813) 489-2422
• CREDIT CARD INFORMATION
• Name as it appears on Credit Card: ______________________________ Type of Card: ________ Amount Paid: $____________
• Credit Card number: ___________________________________ Exp Date: _____________ Security code on back of card: __________
• Billing address of Card:______________________________ City: ____________________ State: __________ Zip Code: ____________
WANT TO PAY BY E-CHECK PAYMENT INFORMATION( ACH TRANSACTION)
• Bank Name:__________________________ Name on Bank Account:______________________ Routing Number:______________________ Account Number:___________________________
• E-Mail Address for your receipt( Must be your official email address): ________________________________
By signing this form, you are authorizing Latin Times Media Inc., Hispanic Resource Foundation, Inc., and it’ s subsidiaries to debit your credit / debit card or Checking account for all services provided to you and for all open balances owed to participate as a client of Latin Times Media, Inc., Your marketing package is described above. Terms: Once Payment is received, your marketing and promotional package begins. Please note Bank Account with transaction details. There are NO REFUNDS on any Payments or Deposits. All Balances paid by credit card are charged a processing fee of 3.99 %. This includes package, which has been pre-purchased and reserved for you, promotion of your business begins immediately upon receipt of this Application / Agreement form. This media service offers limited exclusivity opportunities and by paying / Securing this space, you may also be preventing others with a like business from securing. This Agreement does not imply nor guarantee any exclusivity as to the selling services or products approved by the Latin Times Media, Inc.. I understand there are NO REFUNDS on payments or deposits. If this charge is contested and we receive a notification of Charge Back or NSF during a later date you will be subject to all Court, Legal, and / or collection fees.
• Authorization Signature: ________________________________ Date: _____________________