Authorization of a credit card charge

I, the Master card (8722), credit card holder, hereby authorize OptionsXO to charge my
credit card for services or products purchased by myself in the total amount of 600.00 USD,
as shows below:

Date: 24/02/15 09:35:33 GMT Amount 200.00 USD

Date: 24/02/15 13:45:51 GMT Amount 200.00 USD
Date: 26/02/15 12:46:04 GMT Amount 200.00 USD

Card holder's name:

(As printed on the card)

Address:
(Card's billing address)

Phone number:

Mobile phone number:

Email address:

Credit card Company (Issuer):

Credit card brand: Visa/MasterCard/AMEX/Other

Credit card Number:

CVV (3/4 digits on back of card):

Expiry date:
(Mm/yy)

Card Holder's signature:

Date:

Please fax or scan & email this completed form along with a photo copy of your credit
card (two sides), and a valid proof of identity (national ID or passport) to:

Phone number: +44-2034045709 Fax number: +44-2033265534 Email: support@optionsxo.com