Fillable Credit Card Charge Authorization Form printable pdf download

Credit Card Charge Authorization Form

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CREDIT CARD CHARGE AUTHORIZATION FORM

I hereby authorize _____________________ ("Company") to charge the following amounts to the

credit card account specified below (initial where appropriate before each statement):

_____ The amount of $__________.

_____ Any and all amounts that are or may in the future become due and payable in connection with

any loan agreements or other credit arrangements existing now or in the future between myself and

the Company.

_____ I understand and agree that this Credit Card Charge Authorization Form does not in any way

alter the payment terms contained in any loan agreement or other credit arrangement between myself

and the Company, and that the Company is not obligated to effect any charge authorized hereby at

any time, but rather such charges shall be made only in the Company's discretion.

_____ I understand that I may revoke this authorization by sending written notice of such revocation to

the Company in such time and in such manner as to afford the Company a reasonable opportunity to

act on that written notice. I also understand and agree that any charges authorized by this Credit Card

Authorization Form that are actually charged shall be irrevocable and may not be charged back at any

time in the future.

_____ I affirm that I am at least 18 years old and that I am legally authorized to use the credit card

account specified below.

FILL OUT ALL INFORMATION BELOW COMPLETELY:

Card Type (Circle One):

( Master Card / Visa ) Other: _________________

Cardholder Name (As it appears on Card): ________________________________________

Credit Card Number:

________________________________________

Expiration date (Format MM/YY):

________________________________________

3 Digit code on back of Credit Card:

________________________________________

Card Billing Address:

________________________________________

Card Billing City, State, ZIP:

________________________________________

Cardholder telephone number:

________________________________________

Cardholder signature:

________________________________________

Date:

________________________________________

Credit Card Charge Authorization Form

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