Card – Kings Royal Media

Date*
MM slash DD slash YYYY
Company Name
Your Name*
First Last
Email*
Phone*
Address*
Use address associated with your Credit/Debit card.

Street Address Address Line 2 City State ZIP Code
Card Type?*
- Debit Card
- Credit Card
Card Number (No Spaces)*
Expiration*
Security Code (CVV)*
Hidden
Authorization
I authorize Kings Royal Services LLC (DBA Kings Royal Media) to charge my credit/debit card every month for the amount due.
Authorization*
I authorize Kings Royal Services LLC (DBA Kings Royal Media) to charge my credit/debit card for the amount due.
- Yes
- No
Signature*
Phone
This field is for validation purposes and should be left unchanged.