Credit Card Form

One (1) Time Credit Card Payment Authorization  (please print or or copy in landscape form)

Sign and complete the form to authorize                                                       (sellers name) to make a one time 

charge to your credit card listed below.

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).

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: 

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

SIGNATURE                                                               (cardholder).                 DATE