Xero-Fax, Inc.

            Credit Card-Linked Account Authorization Form

NOTE: This document needs to be filled out ONLY if applying for a credit

            card-linked account.

            Date:________________

            This document hereby authorizes Xero-Fax, Inc. to charge the credit card

            listed below for services rendered.  Invoices will be printed and paid

            automatically with your credit card.  Then, the invoice will be mailed with the

            appropriate reference number and capture number for your credit card

            records.  The invoice can be reviewed for accuracy.

            Please provide the following information:

(Xero-Fax accepts Visa, MasterCard, American Express and Discover)

Company Name: ___________________________________________________

            Card Type:  __ Visa    __ MasterCard    __ American Express    __ Discover

            Card Number: ______________________________________________________

            Expiration Date: ____________________________________________________

            Name as it appears

            on the card (please print):____________________________________________

            Cardholder Address: ________________________________________________

            _________________________________________________________________

            Signature of Cardholder: _____________________________________________

            Telephone: ________________________________________________________

            Please fax this form back to 800-974-9774. 

Thank you for choosing Xero-Fax for all your permitting needs!