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Credit Card Authorization

Have a credit cardholder complete this form to authorize charges to their credit card








Credit Card Authorization


Print and have a credit cardholder complete this single page form to authorize charges on their account. Sections for the credit cardholder's information along with the authorized user are provided. Additional fields include amount, consent/terms, signature and date of the agreement.

CREDIT CARDHOLDER INFORMATION
NAME ON CREDIT CARD
TYPE OF CREDIT CARD VISA | MASTERCARD | AMEX | DISCOVER
TYPE OF ACCOUNT PERSONAL | BUSINESS
COMPANY NAME
CREDIT CARD INFORMATION
ACCOUNT NUMBER
EXPIRATION DATE
BILLING ADDRESS
CITY STATE, ZIP CODE
PHONE EMAIL | FAX
AUTHORIZED USER OF CREDIT CARD
NAME
COMPANY
PHONE NUMBER
EMAIL ADDRESS
IDENTIFICATION
RELATION TO OWNER
TYPE OF CHARGES
AUTHORIZED AMOUNT
DATE OF CHARGES
AUTHORIZATION OF CARD USE

I certify that I am the authorized holder and signer of the credit card reference above.

I certify that all information above is complete and accurate.

I hereby authorize collection of payment for all charges as indicated above. Charges may not exceed the amount listed above in the "AUTHORIZED AMOUNT" field. I understand this is only for up to this amount during the time period of "DATES OF CHARGES" referenced above. If additional charges are going to be authorized a new form will have to be completed.


CARDHOLDER NAME
SIGNATURE/DATE






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