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
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