Credit Card Authorization Form

"*" indicates required fields

In order to reduce charge backs, it is necessary to have a completed credit card authorization form. Also, it is critical to capture an AVS (Address Verification System) match when processing the transaction. Entering the billing zip code lowers risk further and a proof of Identification (Driver’s license or Identification card) is required. We will not keep cards on file and after Card is accepted and transaction is approved the Credit Card info will be deleted.

Card Type:*

VISA

Master Card

Discover

Debit

Card Holder name/organization: (as appears on card):*

CVV2 Code (three-digit number on back of card):*

Last 4 numbers of CC:*

Card Holders Billing Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number:*

Email*

For a copy of this form for your records.

Customers information whom Card will be charged to:

Same as billing address*

Yes

Name/Client Information:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number:*

Charge Amount- Please select one*

I only give permission to Charge my Card for the amount listed below for 1 Transaction.

I give permission to charge my card for the amount listed below and any FUTURE transactions that this Person may need my assistance with.

Amount to be charged.*

Account Name charges will be applied to.*

Upload copy of State Picture I.D.*

Drop files here or

Accepted file types: jpg, png, pdf, doc, Max. file size: 60 MB.

Drivers License, State identification card are accepted.

Signature*

Today's Date:*

Name

This field is for validation purposes and should be left unchanged.