CreditCardAuth

In-City los angeles Division of  Grand Union USA, LLC 807 E 12th Street, Unit 207 Los Angeles, CA 90021 T: 213-747-6300 / F: 213-747-6301 Email: info@in-cityla.com www.in-cityla.com CREDIT CARD AUTHORIZATION FORM   I,______________________________________ authorize In-City los angeles to charge the amount of $_______________on my credit card, on the date of ____/____/______mm/dd/yyyy). CREDIT CARD INFORMATION: NAME AS IT APPEARS ON CARD: CARD TYPE: VISA MASTERCARD AMEX DISCOVER CREDIT CARD #: EXP. DATE: CVV: BILLING INFORMATION: FIRST NAME: LAST NAME: BUSINESS NAME: EMAIL ADDRESS: BILLING ADDRESS: CITY: UNIT #: STATE: ZIP CODE: COUNTRY: PHONE NUMBER: ________________________________________________ (Signature) ________________________ (Date) By signing this form, I confirm that I am the authorized holder of the credit card mentioned above, and I also agree that I will not initiate any dispute on this charge in the future.