Email: XXX
Website; XXX
Phone: XXX
ONE TIME CREDIT CARD PAYMENT
AUTHORIZATION FORM
Sign and complete this form to authorize XXX, LLC to make a one-time debit to your credit listed below.
By signing this form, you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account.
PLEASE COMPLETE THE INFORMATION BELOW:
I _______________________ authorize XXX, LLC to charge my (full name)
Credit card account indicated below for _____________ on or after ________________
(amount) (date)
__________________________________.
(sdescription of goods/services)
Billing Address _______________________ Phone ________________________
City, State, Zip _______________________ Email________________________
| ACOUNT TYPE: VISA O MASTERCARD O AMEX O DISCOVER O Cardholder Name: _______________________ Account Number: ________________________ Expiration Date: ___________________________ CVV2: (3-digit number on back of Visa/MC, 4-digits on front of Amex) ______ |
SIGNATURE: ________________________ DATE: __________________________
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms and conditions outline above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form. THERE ARE NO REFUNDS FOR GOODS OR SERVICES.
______________________________________________________________
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