I agree to pay MPIS, Inc A detective agency for the below type of search. I agree if I'm using a
credit card that this is my card. I also agree to pay this fee to MPIS, Inc. I agree that if I charge
back this transaction that MPIS, Inc may use any means to collect this amount listed below. MPIS, Inc
may also call my credit card company to verify any information about my credit card account to prevent
credit card fraud, and to insure that MPIS, Inc will receive funds for this transaction. Please fax this form
with all fields filled out to 304-788-9041. ALL FIELDS ARE REQUIRED ! You may also mail this form to us
at MPIS, Inc PO BOX 279 KEYSER, WV 26726

Type of search: ______________________________

Price paying:  $___________

Credit card number: ___________________________________

Visa, Master Card, Discover  (Please circle type)

Credit card Exp date: ______________

Billing address: ______________________________________

City/ State/ Zip code: ________________ _____  ___________

Card security code: CVV: _______
Three digit number on the back of the credit card.

Credit card type: _____________________________________
This is the name of the bank, or credit card company that issued
this card to you. Example Capital one, Bank one, Igen

Telephone number of credit card company: _________________
This is the telephone number of the issuing party of your credit card.

I agree that this is my card, and I also agree to this charge stated above.

You name: ____________________________________

Your signature: ________________________________ Date: _________