Credit Card Payment Authorization Template 2 - Free Download
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________________________________________________________________________________________________________
222 Rosewood Drive +1.978.750.8400 Phone info@copyright.com
Danvers, MA 01923 USA +1.978.750.4904 Fax__ www.copyright.com
CREDIT CARD PAYMENT AUTHORIZATION
Date: ______________
Organization Name: ______________________________________________
CCC Customer Account Number:________________________________________________
Cardholder’s Name: ___________________________________
Phone Number: _____________________ Cardholder’s Signature: ______________________
Name of person placing order (if different from above): ________________________________
Credit Card (circle one) MasterCard VISA American Express
Credit Card #: _______________________________________Expiration Date: _________
In Payment of:
Invoice number Amount Due
_______________________ ____________
_______________________ ____________
_______________________ ____________
_______________________ ____________
_______________________ ____________
Total to charge: $_________________
Special Handling Instructions:
Charge total amount due
Charge each invoice individually
Other Special Instructions:___________________________________________________
PLEASE DO NOT E-MAIL THIS FORM.
(E-mail is not a safe way to send credit card numbers.)
Please fax completed from to our secure fax number.
Accounting Dept. Fax Number: 978-750-4904
Fax number from OUTSIDE the USA: 00 + 1 + 978-750-4904
222 Rosewood Drive Danvers, MA 0192
