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iCollaborate Credit Card Authorization Form

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Please print, complete, and submit this form as per instructions below.

I hereby authorize A+ Tutoring Svc., Inc. d/b/a iCollaborate to charge the under-mentioned credit card for services related to my/my company’s use of the iCollaborate online platform. I understand that I will receive a monthly statement detailing all charges.

Your Company Name: ________________________________________________________

Credit Card Information:      Visa             MasterCard            Discover

Name on card: _________________________________________________________

Billing Address: _______________________________________________________

Phone :___________________________________________________________

Payment Option:   (circle one) Bill me monthly            Bill me annually

Payment Amount: $___________

Card # ______________________________________________________________

Today’s Date: ___________  

Credit Card Expiration Date: Month: ________Year:________

Authorized Signature: __________________________________________________

Return this completed form to:

Daniel Ascher, c/o iCollaborate

505 Old York Rd., Suite 6, Jenkintown, PA 19046

Fax: 215.886.0155


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