Hollywood International
Credit Card Authorization Form

I, ____________________________________________________, hereby authorize Blue Rock Entertainment, to make charges in the amount of

$__________________ to my Credit Card in consideration for services or products as requested by me.

Credit Card Type:  Visa ___   MasterCard ___   American Express ___   Discover ___   Other ___
Credit Card Number : _____________________________  

Expiration Date: ______________
Billing Name (as it appears on credit card): _________________________________________

Billing Address (where credit card statements are sent to):
                                                                         _________________________________________
                                                                         _________________________________________
                                                                         _________________________________________

Daytime Telephone Number : __________________________
Evening Telephone Number : __________________________
 

Cardholder signature: ________________________________________________

Date: ________________________

  *** PLEASE PRINT THIS PAGE OUT AND FAX TO 1-800-546-8848.  PLEASE INCLUDE A COPY OF THE CREDIT CARD, BOTH FRONT AND BACK, ALONG WITH YOUR PICTURE I.D. (DRIVER'S LICENSE, MILITARY I.D., ETC.) ***