Original filename: CreditCardAuth.pdf
Author: Hannah Salzman-Gubbay
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Division of Grand Union USA, LLC
807 E 12th Street, Unit 207
Los Angeles, CA 90021
T: 213-747-6300 / F: 213-747-6301
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:
CREDIT CARD #:
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.
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