The Carlson Company LLC

10343 Federal Blvd. Suite J- 401,Westminster, CO 80260

Credit Card Acceptance Form

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Cardholders Name ____________________________________________________________________________________

Credit Card Billing Address _________________________________________________________________________

City _______________________________ State _______________________ Zip Code _________________________

Phone _________________________

Email __________________________________________________

Acct.# ______________________________________________________________________________________________

Card Expiration Date: Month _______________________________ Year ____________________________________

CCV number - Three (3) digits above your signature ________________________________________________________________

Amount to debit:

______________________ Total testing fees

______________________ (Add $20.00 - Return my report by UPS)

______________________ Add 5% - Credit or debit card service fee

______________________ Total Transaction

Cardholder's Signature (required) _________________________________________________________________________________

Date (required) ___________________________

Printed Signature (required) ______________________________________________________________________________________

Refund Policy: If your test is in progress, no refund will be received.

The cardholder will receive an email receipt referencing this debit.