I am a client of VisaRite Services Inc. I hereby authorize VisaRite to charge payment for following service to my American Express card:
   Visa Service
   Passport Service
   Airlines Ticket(s)
   Package Tour(s)

Card Number:	- -
Expiration date:	(MM/YY)
Card Holder Name:
Card identification number:
Amount Authorized:
Billing Address:
City:		State:	Zip:
Tel:
Date:
Signature:			<<< -- Sign Here
By sign this form, you indicate you have read and agree with the terms & conditions set forth by VisaRite.