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:$ _________________
____________________(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.