Please fill out the following information
Indicates required field
Enter your billing address if you know it, otherwise continue to the next step
If this is for recurring payments or to put your card on file, enter RECURRING. Otherwise enter the amount to be charged.
XX / XX (i.e.: 01/25)
3 digit number on back of Visa/MC, 4 digit number on front right of AMEX
I authorize the above named business to charge the credit card indicated 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 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.
I accept and digitally sign.
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