VISA/Mastercard Authorization Form Please print all information. --------------------------------------------------------------------- Your Name:_____________________________________ Address:_______________________________________ City:_______________________State:__________Zip Code:________________ Phone Number:__________________________________ Email Address:_________________________________ Rolling Thunder Games, Inc. Account Number:________________ Credit Card #: _______________ _______________ _______________ _______________ Expiration Date:_______________(Month/Year) Card Type:_______________(Visa or MC or Discover) Authorization Agreement: I authorize Rolling Thunder Games, Inc. to the VISA/Mastercard information I have provided to automatically purchase $ 60.00 of gaming credit, to be placed into my Rolling Thunder Games, Inc. account. I understand that this $ 60.00 will occur automatically whenever my Rolling Thunder Games, Inc. account balance is $ 0.00 or less. I also understand that I may cancel this agreement at any time with a written notice to Rolling Thunder Games, Inc. and that any unused funds in my gaming account can be refunded if so requested. Your signature:___________________________________________________________ Mail completed form to: Rolling Thunder Games, Inc. P.O. Box 460999 Aurora, CO 80046 Phone/FAX: (303) 627-1487 EMAIL: Russ@rollingthunder.com Internet: http://www.rollingthunder.com