New Media, LLC.
3540 W. Sahara Ave. #196
Las Vegas, NV 89102

Non-Disputable Payment Agreement for Credit Card Changes

Please print this form using the print button at the top of your browser.

Name: __________________________________________________

Address: _______________________________________________

City: ___________________ State: _______ Zip: ______________

Phone(s): ______________________________________________

Email: _________________________________________________

Visa/MasterCard:    _______-______-______-_______       ____/____
    Circle One                     Credit Card Number                    Expiration

CVV2       (3 or 4 digit code on back of credit card)           |_______|

Name as it appears Exactly on Card: __________________________

Billing Address (if different from actual address)

Address: ________________________________________________

City: ___________________ State: _______ Zip: _______________

Please circle only 1 type of credit card authorization below:

      |       Every 3 months       |       Monthly       |       One Time Only       |

I, (please print name) __________________________________ hereby authorize New Media, LLC. and/or its designated affiliates to charge my card Monthly, Quarterly or to make current any past due balances by the amount of $____________ until I notify in writing that I am discontinuing my ad. I also agree all charges are final, and there will be no refunds to my credit card. This facsimile is as valid as an original copy.

Card Holder Signature ___________________________________

Please FAX to 702-227-4591
Or scan and email to advertising@usaadultdirectory.com