New Account Form Business Info:Legal Entity Name Doing Business As (DBA) Federal Tax ID Email Business PhoneBusiness FaxContact Info:Contact Name Title PhoneContact Email Billing Address Address Line 2 State City Zip Code Billing & Shipping Address the same Yes No Shipping Address Address Line 2 State City Zip Code Credit Card AuthorizationName on Card Company Name Card # MonthJanuary - 01February - 02March - 03April - 04May - 05June - 06July - 07August - 08September - 09October - 10November - 11December - 12YearPlease enter a number from 2016 to 2040.Card Security Code (CVV) Keep Credit Card on file Select All Yes, Keep Card on file for Recurring Payments No, One time use I Agree to Terms By checking this box I authorize Deprigo Media to charge my purchase on the above referenced Credit Card. In choosing to use this card as a method of payment, I guarantee that there will be no refund for shipping charges (2-way) in the event of a returned shipment due to refusal of delivery. I also guarantee that no “charge-back” will be issued, prior to making contact with Deprigo Media to settle any disputes and acquiring written agreement to perform a “charge-back”. Full Name Date MM slash DD slash YYYY If you would like to download this application for offline use Click Here. Please Email the printed authorization form to Admin@deprigo.com Attn: Credit Department.CAPTCHA Browse Our Services Web Design Promo Products Print Shop
