Credit Card Payment Authorization Form printable pdf download

Credit Card Payment Authorization Form

U.S. MISSION TO GERMANY

Credit Card Payment Authorization Form

Please complete ALL items and sign. Incomplete forms will not be processed.

Credit card type:

□

Master Card

Visa Card

American Express

□

Discover

Credit Card Number:

□□□□□□□□□□□□□□□□□□□□□

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Amount to be deducted:

Expiration Date Month: ________________________

Year: ______________________

Full name as shown on Credit Card: __________________________________________

Name of Applicant: _________________________________________________________

)

(IF OTHER THAN CREDIT CARD HOLDER – ONLY IMMEDIATE FAMILY MEMBERS

Current Address: ____________________________________________________________

____________________________________________________________

Telephone:

____________________________________________________________

Please charge my credit card listed above for the amount shown for the requested

consular service(s). I understand that this charge will be levied in U.S. Dollars.

Signature:

________________________________________

_______________________

Card Holder’s Signature

Date

Updated 09/2012

Credit Card Payment Authorization Form