Please print out this form,

Card Holder Personal Information:

Name:__________________________     

                         
Phone Number_____________________________

Address _________________________City

__________________State________________Zip____________

I, _____________________ give permission to One Source Service

 to charge may credit card for the amount of $___________US Dollars

For the purchase of __________________________________________________________

Credit Card Number    _________  _________  _________  __________     

Expiry Date:____________

Name on Card: ______________________________________________

I understand that the amount will be converted to Canadian dollars and charged in Canadian dollars and the amount appearing on my statement may not be the exact same amount as above due to fluctuating exchange rates.

Signature _____________________________________    

Date: _____________________