Credit card authorization form with an option to allow for automatic billing.
By signing this document, you agree to allow Sender's Company to process your credit card.
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
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.