Credit Card Payment Authorization Form


One Time Credit Card Payment Authorization Form
Sign and complete this form to authorize Longhorn Aquatics 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:
Longhorn Aquatics
I ________________________________ authorize
to charge my credit card
(full name)
account indicated below for _______________ on or after _________________. This payment is for
(description of goods/services)
Billing Address ____________________________
Phone# ______________________________
City, State, Zip ____________________________
Email ________________________________
Account Type:
(Discover and American Express are not accepted)
Cardholder Name _____________________________________________________
Account Number
Expiration Date
CV2 (3 digit number on back of Visa/MC) __________
I authorize the above named business 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.
Form Received by ___________________________________ Date ___________________
Charged by ________________________________________ Date ____________________


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Parent category: Business