Tuesday, August 14, 2018


PLEASE PRINT V E R Y  V E R Y CLEARLY &  THOROUGHLY THEN EMAIL to Capitalcash7@gmail.com or text to 312-218-8737
Print Cardholder Name:_________________________________________________________________ 

Signature: ________________________________________________________________________________

Address:  __________________________________________________________________________________
Credit Card Type:
                        ________ VISA________ MASTERCARD _________ DISCOVER  _________AMEX
Credit Card Number:
    __________- _________ - __________ - ___________

Expiration Date:                          Billing Zip Code:         Phone Number For Credit Card:                                    
________ / ________      ____________       ______________

Card Identification Number (last 3 digits on back of the cc): _______________________ 

___ yes copy of a drivers license id sent in to verify ownership of credit card

Amount Charged:$ _________________   

I ______________________________________________________________(signature) ____________________(Date) I authorize this form as permission 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 an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.