Microsoft Word - Credit Card Authorization Form
Virginia Department of Social Services (VDSS)Neighborhood Assistance Program (NAP)Credit Card Authorization Form As the Individual card holder, I hereby authorize this card to be used for a donation to a NAP organization for which I may be eligible for a tax credit. As the company representative, I hereby authorize this card to be used for a donation to a NAP organizationfor which my company may be eligible for a tax credit. Credit Card Information:Name of business, if applicable: Name as it appears on the Card:(also include name of representative if business): Type of Card: VISA MASTERCARD DISCOVER AMERICAN EXPRESSCredit Card Number: (*last 4 digits) Amount of Donation: (after any fees paid by donor): Address: Street City, State, Zip Telephone Number: Name of NAP Organization: I hereby authorize this card to be used for a donation made to the above NAP organization:__________________________________________ _______________Signature of Cardholder or Company Representative: Date:NAP organization: Please submit this form along with the credit card charge receipt certifying the donation was charged to the donor’s credit card account.Revised 4/17 ................
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