Русское телевидение в Америке 
Russian Internet TV America 

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Automatic Credit Card Billing Authorization Form

If you would like to enjoy the convenience of automatic billing, simply complete the Credit Card Information section below and sign the form. All requested information is required. Upon approval, we will automatically bill your credit card for the amount indicated and your total charges will appear on your monthly credit card statement. You may cancel this automatic billing authorization at any time by contacting us.

E-mail *	addresses like *@aol.com is not supported
Customer name: *
Login number: *
Phone: *
I authorize Nash Dom TV to automatically bill the card listed	below as specified:
Amount: $ *
TAX for NY State residents	Yes
Frequency: *	Monthly     Quarterly
Start billing on: *
End billing when: *	Customer provides written cancellation
Credit card type: *	Visa     MasterCard
Credit card number: *
Credit card Expires: *
Cardholder's name: *
Cardholder's Zip code: *	(from credit card billing address)
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