AI GLOBAL MEDIA LTD, First Floor, Suite F, The Maltsters. 1-2 Wetmore Road, Burton Upon Trent, Staffordshire. United Kingdom. DE14 1LS. Company Reg No: 074000916 | VAT Reg No: 100 3617 75

AI GLOBAL MEDIA LIMITED –

CREDIT CARD AUTHORISATION FORM

COMPANY NAME: CARDHOLDERS NAME: ACCOUNT/INVOICE NUMBER: INVOICE AMOUNT: £ TYPE OF CARD (I.E VISA/MASTERCARD/AMEX): 3% charge is applicable to all credit card payments DEBIT CARD: CREDIT CARD: CARD NUMBER: START DATE: EXPIRY DATE: SECURITY CODE: ISSUE NUMBER (IF APPLICABLE): ADDRESS: TELEPHONE NUMBER: EMAIL ADDRESS:

PLEASE NOTE: 3% PROCESSING FEE APPLIES TO ALL CREDIT CARD TRANSACTIONS

By completing this form you acknowledge and authorize AI Global Media Ltd to charge your credit card for the total invoice amount plus the above mentioned processing fees.