Automatic Credit Card Deduction Authorization

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Automatic Credit Card Deduction Authorization
Name: ________________________________________________________________________
Address: ______________________________________________________________________
Phone Number: ________________________________________________________________
Email: ________________________________________________________________________
Credit Card Number: _________________________________________
Expiration Date: _____/____/______
[ ] Master Card
[ ] Visa
[ ] Discover
[ ] American Express
[ ]
I authorize ____________________________________________ to charge my credit card
$__________ on revolving timeframe:
_____ Monthly
_____ Quarterly
_____ Yearly
[ ]
I authorize _____________________________________________ to charge my credit card one
time for the following amount:
$__________.
_____________________________________________________________________________
Signature of Card Holder
Date
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