LLLeads

Billing & Contact Form

First Name

Last Name

Phone

Company Name

Address Line 1

Address Line 2 (optional)

City

State / Province

Zip / Postal Code

Country

Payment Information

Card Number

Name on Card

Expiry (MM/YY)

CVD

I, the undersigned, authorize LLLeads.com to make weekly debits to the credit card described above. The weekly payment for LEADS will correspond to an amount equal to the number of leads provided (calls and forms) multiplied by the amount agreed upon for the cost of the LEAD, plus taxes. This is applicable whether the calls (LEADS) were answered or not. A record of LEADS (calls and forms) is available. The client may revoke this authorization at any time, with 2 business days written notice. No long-term changes will be made. The client further certifies that all persons whose consents are necessary for the operation of the card identified above have approved this authorization.

Additional Comments

I confirm that I have read and agree to the terms.

Signature