ࡱ> FHEy bjbj 44{{JJJJJ^^^^t^ .6888888$M!\J===\JJqsss=.JJ6s=6ssRޞ|k4j"0r,!!!J/0_"s///\\i ///====!///////// :  < Street Address> < City State Zip> < Phone Number> One Time Credit Card Payment Authorization Form Sign and complete this form to authorize to make a one time debit to your credit card listed below. By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account. Please complete the information below: I  FORMTEXT ____________________________ authorize to charge my credit card (full name) account indicated below for  FORMTEXT _____________ on or after  FORMTEXT ___________________. This payment is for (amount) (date)  FORMTEXT _____________________________________. (description of goods/services) Billing Address  FORMTEXT ____________________________ Phone#  FORMTEXT ________________________ City, State, Zip  FORMTEXT ____________________________ Email  FORMTEXT ________________________ Account Type:  FORMCHECKBOX  Visa  FORMCHECKBOX  MasterCard  FORMCHECKBOX  AMEX  FORMCHECKBOX  Discover Cardholder Name  FORMTEXT _________________________________________________ Account Number  FORMTEXT _____________________________________________ Expiration Date  FORMTEXT ____________ CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX)  FORMTEXT ______  SIGNATURE DATE I authorize the above named business 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. 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