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 Information

Billing Address  Phone#  

City, State, Zip,  

Card Details

Cardholder Name  

Account/CC Number  

Expiration Date  


Zip Code  

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 long
as the transaction corresponds to the terms indicated in this form

Leave this empty:

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Acom Technologies
Signature Certificate
Document name: One (1) Time Credit Card Payment Authorization
lock iconUnique Document ID: 515bf426985e514a95791b68250a94aef8b3a217
Timestamp Audit
March 15, 2022 3:22 pm ESTOne (1) Time Credit Card Payment Authorization Uploaded by Acom Technologies - IP