Automatic Credit Card Deduction Authorization
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Use this form to have a Credit Card holder authorize deductions from their card on either a one time basis or
on a re-occuring timeframe.
Name:
________________________________
Address: _________________________
City: __________ State: ___ Zip: ____
Phone Number:
________________________________
Email:
________________________________
Credit Card Number:
________________________________
Expiration Date: __/__/____
[ ] Master Card
[ ] Visa
[ ] Discover
[ ] American Express
[ ]
I authorize ____________ to charge my credit card
$__________ on revolving timeframe:
_____ Monthly
_____ Quarterly
_____ Yearly
[ ]
I authorize ____________ to charge my credit card
one time for the following amount:
$__________.
_______________________ Date_____
Signature of Card Holder
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