Credit Card Payment Form printable pdf download

Credit Card Payment Form

Please complete the following information

Account Number _______________________

Company Name ________________________________________________________________________

Card Issuer

Visa

MasterCard

Discover

American Express

□

Name on Card ________________________________________________________________________

Card Number ________________________________________________________________________

Expiration Month / Year ____________________________

Security Code ___________________

Card Billing Address ___________________________________________________________________

City _____________________________________________

State ________________________

Postal Code ___________________

□

Check here if this is an update to your billing address

By my signature, I authorize DAT to charge my credit card & account number listed above. I under-

stand payment for my current invoice will be charged to my crredit card at the time of billing. I further

authorize the above listed credit card company to accept this letter in lieu of my signature.

Signature ______________________________________________________________________________

(Please print) Name ___________________________________________________________________

Date ________________

Phone Number ________________________________________

Please fax this completed form to DAT, Billing Services Department 1-800-328-5316

PO Box 23519 | Portland, OR 97281-3519 | 8405 SW Nimbus Avenue | Beaverton, OR 97008

Telephone 1-800-547-5417 | Fax 1-800-328-5316

Credit Card Payment Form