Credit Card Authorization Form
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1-‐OFFICIAL-‐
CREDIT
CARD
AUTHORIZATION
F ORM
CREDIT
C ARDHOLDER
INFORMATION
NAME
ON
CREDIT
C ARD
TYPE
O F
CREDIT
CARD
V ISA
M C
AMEX
DISCOVER
OTHER
CARD
N UMBER
EXPIRATION
D ATE
BILLING
ADDRESS
CITY
STATE
ZIP
C ODE
PHONE
EMAIL
FAX
N UMBER
AUTHORIZED
USER
O F
CREDIT
C ARD
NAME
COMPANY
PHONE
N UMBER
EMAIL
ADDRESS
DRIVER’S
L ICENSE
N UMBER
RELATION
T O
OWNER
TYPE
O F
CHARGES
AUTHORIZED
AMOUNT
DATE
O F
CHARGE
AUTHORIZATION
O F
C ARD
U SE
___
-‐
I
c ertify
t hat
I
a m
t he
authorized
h older
a nd
signer
o f
t he
credit
c ard
r eference
above.
I
c ertify
that
all
i nformation
a bove
is
c omplete
a nd
accurate.
___
-‐
I
h ereby
authorize
c ollection
o f
p ayment
for
a ll
c harges
as
i ndicated
a bove.
Charges
m ay
n ot
exceed
t he
amount
listed
a bove
in
t he
“AUTHORIZED
A MOUNT”
f ield.
I
u nderstand
this
i s
o nly
for
u p
to
this
a mount
during
t he
time
p eriod
o f
“ DATES
O F
CHARGES”
r eferenced
above.
If
a dditional
charges
are
g oing
t o
be
authorized
a
n ew
form
w ill
h ave
t o
be
completed.
CARDHOLDER
N AME
SIGNATURE
DATE
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Parent category: Business