10 Union Ave. Ste 10

Lynbrook, NY 11563

718-322-8132

 

Credit Card Authorization Form

Today’s date://

I:

As the card holder, I hereby authorize this card to be used for the deposit required for

invoice # in the amount of $plus 4% credit card processing fee.

 

Credit Card Information:

Name as it appears on the Card:

Type of Card:   VISA MASTERCARD    DISCOVER  AMERICAN EXPRESS

Credit Card Number- - -

Expiration Date/ ---

Security Code BACK of Visa OR Master Card: (3 digits)

Security Code FRONT of Amex Card: (4 digits)

 

Credit Card Billing Address: 

Street:

City: State: Zip Code:

Telephone:

Cardholder or Company Representatives Signature:________________________________________

Date: //

    I hereby authorize this card to be used for the future deposits and or final payment.

  Please sign again for future authorization:

  ___________________________________________________________

  This Authorization can be faxed to 718-322-7390 or emailed to docs@asikchb.com