One (1) Time Credit Card Payment Authorization
Sign and complete this form to authorize to make a one-time charge 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 date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account
I authorize to charge my credit card account indicated below
for $ on date .
This payment is for .
Billing Address Phone#
City, State, Zip,
I authorize the above named business to charge the credit card 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 (1) time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so longas the transaction corresponds to the terms indicated in this form
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Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: One (1) Time Credit Card Payment Authorization
Agree & Sign