Authorization for Credit Card Use

 

Name as it appears on credit card  
Credit Card Number  
Expiration Date  
Type of Card (circle one) Visa   MC   Amex   Discover
3 Digit CV # (on back of card)  
Address used for this card  
Zip Code used for this card  
Unit #  
Phone #  

 

  • Monthly Recurring for Dues Payment of $_________

(The ______ day of every month)

 

  • One time Payment for ________________________

(which Months, year)

in the amount of $_________

 

______________________________            ___________

Authorized Signature                                                                          Date