CreditCardAuth (PDF)

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.