Verification Of Employment Credit Card Authorization

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320 S. Milliken Ave. Ste A 
 
Ontario, CA  91761 
 
(909) 390‐9404 ◊ (909) 390‐9510 fax 
 
 
VERIFICATION OF EMPLOYMENT
CREDIT CARD AUTHORIZATION 
 
 
Requested Date:
Requester Name:
Requester fax number:
Requester Email:
Requester phone number:
Requester Address:
Credit Card Type:
Visa
MasterCard
American Express
Discover
Cardholder’s Billing Address:
Credit Card Number:
Expiration Date:
/
/
*CVV Code:
*Discover, MasterCard and Visa – 3 digit CVV code (card verification value) on the back of the card.
American Express – 4 digit CVV code (card verification value) on the front of the card.
Total amount of transaction:
$20.00
Authorized Cardholder Signature: X
(By signing above you agree to be charged $20.00 for one employment verification on the employee listed below)
Name of employee:
***Executed credit card authorization form must be accompanied by an employee signed release***
Receipt Requested:
Yes or
No
If you answer yes, please let us know if you would like it:
faxed or
emailed

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