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Blank Credit Card Authorization Form

A credit card owner can allow another person to purchase a merchandise through her/his credit card by fulfilling this form. A fulfilled copy of this form is valid for one-time use only.Download

Extracted Text for Proper Search

CREDIT CARD AUTHORIZATION 	
 
Go to www.AtYourBusiness.com for more free business  forms 
 	
CREDIT CARDHOLDER INFORMATION 
NAME ON CREDIT CARD 	 	
TYPE OF CREDIT CARD 	VISA 	MC 	AMEX 	DISCOVER 	OTHER 	
TYPE OF ACCOUNT 	PERSONAL 	BUSINESS 	
COMPANY NAME 	 	
 	
ACCOUNT NUMBER 	 	
EXPIRATION DATE 	 	
BILLING ADDRESS 	 	
CITY 	 	STATE 	 	ZIP CODE 	 	
PHONE 	 	EMAIL 	 	FAX NUMBER 	 	
 	
AUTHORIZED USER OF CREDIT CARD 
NAME 	 	
COMPANY 	 	
PHONE NUMBER 	 	
EMAIL ADDRESS 	 	
IDENTIFICATION 	 	
RELATION TO OWNER 	 	
TYPE OF CHARGES 	 	
AUTHORIZED AMOUNT 	 	
DATES OF CHARGES 	 	
 	
AUTHORIZATION OF CARD USE 
 
I certify that I am the authorized holder and signe r of the credit card reference above. 
 
I certify that all information above is complete and accurate. 
 
I hereby authorize collection of payment for all ch arges as indicated above. Charges may not exceed 
the amount listed above in the “AUTHORIZED AMOUNT”  field.  I understand this is only for up to this 
amount during the time period of “DATES OF CHARGES” referenced above. If additional charges are 
going to be authorized a new form will have to be completed. 
 	
 	
CARDHOLDER NAME 	 	
SIGNATURE 	 	DATE
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