Name: __________________________________________________________ Company: _______________________________________________________ Address: ________________________________________________________ City: ___________________________________________________________ State: _______________ Zip: _______________ Phone: _________________________________________________________ URL: ___________________________________________________________ Email: __________________________________________________________ Company Description / Type: _______________________________________ Card Type (YOU MUST CIRCLE ONE) American Express | Discover | MasterCard | Visa Credit Card Number: ______________________________________________ 3-4 Digit Verification Number (on back of credit card) __________________ Expiration Date: _________________________________________________ Total Amount to be Billed: _________________________________________ I have read and agree with the Policy Statement of Witty 1® Productions, Inc., as outlined on their website: www.witty1.com. I hereby grant my permission and authorization for my Credit Card to be billed in the amount set above for the following professional services: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Date: ______________ Signature: __________________________