Credit Card Form

 

 

Payment method:

Visa card

Master card

JCB card

 

Credit card charge authorization

 

Please obtain cardholder's signature on this form and return it with copy of the credit card front & back sides in order to verify authorization.

 

 

I here by authorize                      to charge my credit card in the amount listed below. The issuer of this card is authorized to ay the amount shown upon proper presentation I agree to pay such amount (together with any other charges due there on) subject to and in accordance with, the agreement governing the use of such card.

  

 

 

Complete all blanks, sign and return

 

 

Amount: ..............................................................

Card number: ......................................................  Expiration date:.....................

For: ...................................................................................................................(Full name if other than cardholder)

Print name as it appears on card: .........................................................................

Passport number: ................................................................................................

Cardholder's address: ................................................. Zip:..................................

Tel. home: .................................................................  Tel. office:........................

Signature of cardholder: .......................................................................................

 

                                                         Date:                                            Signature:

                                                    ...................                                     .....................