Name *

as it appears on your credit card

First Name

Last Name

Phone *

(###)

###

####

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Credit Card Authorization *

Credit cards on file will automatically be charged after 5 days from completion of service if payment is not received, and any credit card transactions will have an additional 3% surcharge.

I authorize Fung Medic & Safety inc. to charge my credit card above for agreed upon services. I understand that my information will be saved to file for future transactions on my account.