I hereby represent all information is true, correct and complete. By placing my/our full name and date of birth in the indicated boxes I/we affirm my/our signature to be acceptable as a written signature. I/we authorize the release of any credit information, business or personal to be released to the submitter, its assigns or the above named vendor. Submitter complies with section 326 of the US Patriot Act. This law mandates that submitter or its assigns request and verifies certain information about you and your company. A copy or fax of this authorization shall be valid as the original.
Have a question? Please call US Capital Support at 815-477-1600 x1363 or e-mail at firstname.lastname@example.org