Credit Card Authorization .pdf

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Original filename: Credit Card Authorization.pdf
Title: One Time Credit Card Payment Authorization Form
Author: PaySimple

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172 North Division Street
Auburn, New York 13021 Phone # 1-800-233-3799

Fax back to

315-253-4338

One Time Credit Card Payment Authorization Form
Sign and complete this form to authorize Gallace Auto Dismantling d/b/a Kubis Auto Parts
to make a one time debit to your credit card listed below.
By signing this form you give us permission to debit your account for the amount indicated
on or after the indicated date. This is permission for a single transaction only, and does not
provide authorization for any additional unrelated debits or credits to your account.
Please complete the information below:
I ____________________________ authorize Kubis Auto Parts to charge my credit card
(full name)

account indicated below for _____________ on or after ___________________. This payment is for
(amount)

(date)

___________________________________________________.
(description of goods/services)

Billing Address ____________________________

Phone# ________________________

City, State, Zip ____________________________

Email ________________________

Account Type:

Visa

MasterCard

Discover

Cardholder Name _________________________________________________
Account Number

_____________________________________________

Expiration Date

____________

CVV2 (3 digit number on back of Visa/MC ) ______

CARDHOLDER SIGNATURE

___________

DATE

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. Signing this enters you into a legally
binding contract with Kubis Auto Parts.


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