Credit Card Authorization Form

Credit card authorization form with an option to allow for automatic billing.


Sender's Company

Sender's Address

By signing this document, you agree to allow Sender's Company to process your credit card.

Payer's Information

Company Name on Card (if any)Receiver's Company

Name on Card: Receiver's Name

Billing Address:Receiver's Address

Credit Card Type: (Select one) _X_ Visa ___Mastercard ___Discover ___AmEx

Credit Card Number: xxxx xxxx xxxx xxxx

Expiration Date:01/16

Card Identification Number: xxx Last 3 digits located on the back of the credit card, front if Amex

One Time Payment Authorization

Charge Amount: $ Charge Amount (USD)

I authorize Sender's Company to charge the amount listed above to the credit card provided herein. I agree to pay for this purchase in accordance with the issuing bank cardholder agreement.

Automatic Payment Authorization (optional)

If you do not want automatic payments, enter $0 in the maximum payment field.

I authorize Sender's Companyto charge this credit card amounts outstanding on my account based on the terms outlined in any PO or invoice that has been authorized by my company without any further notice or authorization as long as the total charge does not exceed $ 5,000. If it exceeds this amount, I will first need to approve the charge.

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This is version 3, from 7 years ago.

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