Credit Card Authorization

ONE TIME CREDIT CARD PAYMENT AUTHORIZATION FORM

Please sign and complete this form to authorize Solution dynamics, Inc. to make a one time debit to your credit card listed below.

By signing this form, you give Solution Dynamics, Inc. permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

Please complete the information below:

I _________________________________________(name) authorize Solution Dynamics, Inc. to charge my credit card account indicated below for

______________________________________ (amount)

on or before: ___________________________ (date)

This payment is for: ___________________________________________________________ (description of goods)

Account Type: ____ Visa _____ Mastercard ____ AMEX ____ Discover

Cardholder Name: ________________________________________

Account Number: _________________________________________

Expiration Date: _________________

Security Code: __________________

Signature: _______________________________________________

Date: __________

I authorize the above named business to charge the credit card indicated in this authorization from according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

Please fax form to: Solution Dynamics Inc. 262-521-5733