One Time Credit Card Payment Authorization Form - Ah Wilkens

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A.H. Wilkens Auctions & Appraisals
299 Queen Street East, Upper Gallery
Toronto, Ontario
M5A 1S7
P: 416.360.7600
FAX: 416.360.8900
One Time Credit Card Payment Authorization Form
Sign and complete this form to authorize A.H. Wilkens Auctions & Appraisals Inc. to
make a one time debit to your credit card 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 A.H. Wilkens Auctions & Appraisals Inc. to charge
(full name)
my credit card account indicated below for _____________ on or after ___________________.
(amount)
(date)
This payment is for _____________________________________.
(description of goods/services)
Billing Address ____________________________
Phone# ________________________
City, State, Zip ____________________________
Email ________________________
Account Type:
Visa
MasterCard
Cardholder Name _________________________________________________
Account Number
_____________________________________________
Expiration Date
____________
CVV2 (3 digit number on back of Visa/MC) ______
Signature ____________________________

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