Fillable Authorization for Credit Card Use

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Authorization for Credit Card Use

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The Authorization for Credit Card Use form is 1 page long and contains:

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  • 3 check-boxes
  • 8 other fields

Country of origin: OTHERS
File type: PDF

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Authorization for Credit Card Use
PRINT AND COMPLETE THIS AUTHORIZATION AND RETURN.
All information will remain confidential
Name on Card: __________________________________________________________
Billing Address: __________________________________________________________
__________________________________________________________
Credit Card Type: Visa Mastercard Discover AmEx
Credit Card Number: _____________________________________________
Expiration Date: ____________________
Card Identification Number: ______ (last 3 digits located on the back of the credit card)
Amount to Charge: $ ________________ (USD)
I authorize Credit Technology, Inc. to charge the amount listed above to the credit card
provided herein. I agree to pay for this purchase in accordance with the issuing bank
cardholder agreement.
Cardholder – Please Sign and Date
Signature: ___________________________________________
Date: ___________________________________________
Print Name: ___________________________________________
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Authorization for Credit Card Use

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Completed 15 March 2021

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