Credit Card Payment/refund Authorization Form printable pdf download

Credit Card Payment/refund Authorization Form

< Street Address>

< City State Zip>

< Phone Number>

Credit Card Payment/Refund Authorization Form

Sign and complete this form to authorize

to make a one-time

debit/credit to your credit card listed below.

By signing this form you give us permission to debit/credit your account for the amount

indicated. This is permission for a single transaction only, and does not provide

authorization for any additional unrelated debits or credits to your account.

Please complete the information below:

I ____________________________ authorize

to charge my credit card

(full name)

account indicated below for _____________ on or after ___________________. This payment is for

(amount)

(date)

_____________________________________.

(description of goods/services)

Billing Address ____________________________

Phone# ________________________

City, State, Zip ____________________________

Email ________________________

SIGNATURE

_________________

DATE

I authorize the above named business to charge the credit card indicated in this

authorization form according to the terms outlined above. This payment authorization is for

the goods/services described above, for the amount indicated above only, and is valid for

one time use only. I certify that I am an authorized user of this credit card and that I will

not dispute the payment with my credit card company; so long as the transaction

corresponds to the terms indicated in this form.

Account Type:

Visa

MasterCard

AMEX

Discover

Cardholder Name _________________________________________________

Account Number

_____________________________________________

Expiration Date

____________

Credit Card Payment/refund Authorization Form