Credit Card Authorization Letter

CREDIT CARD AUTHORIZATION LETTER

_________________

(Date)

I, _____________________________ give permission for ___________________________

(Cardholder’s Name)

(Patient’s Name)

to use my _____________________ on _______________ at Planned Parenthood League

(Credit Card Type)

(Date of Service)

of Massachusetts in the amount up to _______________.

(Payment Amount)

is a number you can reach me at to confirm that I have given

_____________________

(Telephone Number)

permission to use my credit card for the amount specified.

__________________________________________

Print name as it appears on credit card

__________________________________________

Signature as it appears on credit card

__________________________________________

Credit card number

____________

_____________

Billing Zip Code

Expiration Date

CVV Code

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Parent category: Letters