D.I.M. Stone Inc.

One-time Credit Card Authorization

This form is for making a one-time credit card payment for purchases to D.I.M. STONE

Name on card:  
Player/Account number:  
Amount of charge: $ ,

Card type: AMEX - American Express VisaMastercard

My card number is: expiration month: 010203040506070809101112 year: 20062005200620072008200920102011  CCV #

Your email: (for a confirmation email)