One Time Credit Card Payment Authorization Form
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45065 Riverside Parkway
Ashburn, VA 20147
571-223-3939
One Time Credit Card Payment Authorization Form
Sign and complete this form to authorize Interior Business Center to charge to your credit card listed below.
By signing this form you give us permission to charge your credit card for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.
Please complete the information below:
I ____________________________ (full name) authorize the National Transportation Safety Board via Interior Business Center to charge my credit card account indicated below for
_____________ plus $100 offline processing fee and $25 invoice processing fee, if applicable.
(tuition amount) on or after ________________________________
(date)
This payment is for
_____________________________________ ______________________________
(Title of Course and Date of Course)
Billing Address ____________________________ Phone# ________________________
City, State, Zip ____________________________ Email ________________________
| Account Type: Visa MasterCard AMEX Discover Diners Club |
| |
|Cardholder Name _________________________________________________ |
|Account Number _____________________________________________ |
|Expiration Date ____________ |
|CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX) ______ |
SIGNATURE DATE
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
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