Credit Card Authorization Agreement
Credit Card Authorization Agreement Date: ____________ Name: ___________________________ Address: _______________________________ City: __________________________________ Email: _________________________________ Amount of Payment: $____________________
Phone: ___________________
Full Name of Card Holder if different from above: _____________________________ Card Holder’s Address: ___________________________________________________ Card Holder’s Day Time Phone Number: _____________________________________ Credit Card # ______________________________________________ V-Code (3 digit # on back of card) _____________________________ Type of Card:
VISA
Master Card
Discovery
AMEX
Expiration Date of the Card: ___________________ Approval # _________________ I understand that the amount shown above will be a one time charge to my credit card for payment of ordered goods. I agree that when I authorize a credit transaction, the order will be subject to cancellation for non-payment if the club is unable to collect payment from the credit card company.
Card Holder Signature: _____________________________________ Date: _________
Phone: ___________________
Full Name of Card Holder if different from above: _____________________________ Card Holder’s Address: ___________________________________________________ Card Holder’s Day Time Phone Number: _____________________________________ Credit Card # ______________________________________________ V-Code (3 digit # on back of card) _____________________________ Type of Card:
VISA
Master Card
Discovery
AMEX
Expiration Date of the Card: ___________________ Approval # _________________ I understand that the amount shown above will be a one time charge to my credit card for payment of ordered goods. I agree that when I authorize a credit transaction, the order will be subject to cancellation for non-payment if the club is unable to collect payment from the credit card company.
Card Holder Signature: _____________________________________ Date: _________
