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