Credit Card Authorization Form

PLEASE PRINT OUT AND COMPLETE THIS AUTHORIZATION AND RETURN TO US.
All information will remain confidential.

Cardholder Name:

___________________________________________

Billing Street Address: __________________________________________

State: __________________ Zip Code: ____________

Credit Card Type: _____ Visa

_____ Mastercard

____ Discover

_____ American Express

Credit Card Number: ___________________________________________

Expiration Date: ___________________________________________

Security Code: ___________________________________________

Charge Amount:       $

________________ (USD)

I authorize ___________________________ to charge the agreed amount listed above to my credit card provided herein. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement.

Cardholder – Print Name, Sign and Date Below: Signed: ___________________________________________ Dated: ___________________________________________ Name: ___________________________________________

Once signed return the completed form to:

__________________________________________

__________________________________________

__________________________________________

__________________________________________