Authorization for Credit Card Use

Authorization for Credit Card Use

PRINT AND COMPLETE THIS AUTHORIZATION AND RETURN.

All information will remain confidential

Name on Card:               ___________________________________________

Billing Address:                 ___________________________________________

                                        ___________________________________________

Credit Card Type:           _____ Visa     _____ Mastercard   ____ Discover _____ AmEx

 

Credit Card Number:    ___________________________________________

 

Expiration Date:               ___________________________________________

Card Identification Number:  ______ (last 3 digits located on the back of the credit card)

Amount to Charge:  $ ________________ (USD)

I authorize ___________________________ to charge the amount listed above to the credit card provided herein. I agree to pay for this purchase in accordance with the issuing bank cardholder agreement.

Cardholder – Please Sign and Date

Signature:                          ___________________________________________

Date:                                  ___________________________________________

Print Name:                       ___________________________________________

Return the completed and signed form to the following:

__________________________________________

__________________________________________

__________________________________________

__________________________________________