International Advertising Payment Form

International Advertising Credit Card Authorization, please fill out the following Secure-Online order form.

All areas with asterisk (*) MUST BE FILLED.

All payments are non-refundable once submitted.

Advertising Information
*First Name
*Last Name

International Billing Information
*Address
*City
*State/Province/Region
*Postal / Zip Code
*Country
*Phone Fax
*Email
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International Mailing Information (If Different)
Address
City
State/Province/Region
Postal / Zip Code
Country
Phone Fax
Email

Credit Card Information
*Card Type VISA MasterCard American Express Discover
*Name on Card
*Number
*CCV Number
*Expir. Date [MM/YYYY]
Please note that we do not accept multiple-pay orders, Debit Card or Electronic Check transactions.

In addition, we are not responsible for any overdraft fees or other bank charges you may incur as a result of your advertising purchase.

Notes

Electronic Signature & Verification
* Checking this box verifies this as my electronic signature.
By submitting this form I hereby authorize The Canine Chronicle to keep my credit card payment information on file.