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Credit Card Form
One (1) Time Credit Card Payment Authorization (please print or or copy in landscape form)
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Sign and complete the form to authorize (sellers name) to make a one time
charge to your credit card listed below.
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By signing this form,you give us permission to debit your account for the amount indicated on or after the indicated date.
This is permission is for a single transaction only, and does not provide authorization for any additional unrelated debits
or credits to your account.
I (buyers name) authorize (sellers name) to charge my credit
card account indicated below for the $ ( amount plus sales tax) on (
(date)
The payment is for (description of goods/service).
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Billing Information
Billing Address .Phone #
City,State,Zip . Email
(Visa, Mastercard,Discover,American express) circle card type.
Cardholders name:
Credit Card Number :
Expiration Date :
CV V : ( 3 numbers usually at the back of card)
Zip Code:
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I authorize the above named person /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 the authorize user
of this card and will not dispute the payment with my company so long as the transaction corresponds to the
terms indicated on this form
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SIGNATURE (cardholder). DATE
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