Credit Card Payment Authorization, Registration Form

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One Time Credit Card Payment Authorization Form
Sign and complete this form to authorize
Liganeua Club
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.
A scanned copy of your ID should accompany this form.
Please complete the information below:
I ____________________________ authorize
Liganuea Club
to charge my credit card
(full name)
account indicated below for _____________ on or after ___________________. This
payment is for
(amount)
(date)
Hotel Room Accommodations
Billing Address: ____________________________
Phone#:
________________________
City, State, Zip :____________________________
Email:
________________________
Account Type:
Visa
MasterCard
AMEX
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 Liguanea Club to charge the credit card indicated in this authorization form according to the terms outlined 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.

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