Credit Card Information Faxing Form
for Simutronics Corporation
Form last updated: 09/07/2001
Print Form

NOTE! If you would like to pay with a credit card on our secure website, you can do so in the MY ACCOUNT area. This form is only for those who wish to fax in their credit card information rather than submit it over the Internet.

Please fax this completed form to play.net at 636-940-8722

Customer Information

First Name:		 ______________________________________________

Middle Initial:		 ______________________________________________

Last Name:		 ______________________________________________

Internet Email Address:		 ______________________________________________

play.net Account Name:
 ______________________________________________
(if applicable)  

Account Security Code Information (about)
(The default security question is "What is your mother's maiden name?" You may have changed it when you originally signed up.)

Security Question:		 ______________________________________________

Security Answer:		 ______________________________________________
 
Credit Card Information
Your name as it appears on the credit card: ______________________________________________

Your credit card number:		 ______________________________________________

Your credit card's expiration date:		 ______________________________________________
 
I (we) authorize my credit card company to make my Simutronics payments on my (our) behalf for the accounts indicated above for any balances owed, including monthly subscription fees and any other purchases or fees. I understand that I am in full control of my payments. If I choose to discontinue this arrangement, I will immediately notify Simutronics Corporation in writing.
 
Signature:		 ______________________________ Date: ________________
 
Signature:		 ______________________________ Date: ________________

Please fax this completed form to play.net at 636-940-8722