Microsoft Word - Credit Card Authorization Form.docx
Auction Gallery of the Palm Beaches, Inc.
1609 So. Dixie Highway, Suite 5, West Palm Beach, FL 33401
Credit Card Authorization Form
CARDHOLDER INFORMATION
Name:
Billing Street Address:
City: State: Postal Code:
Country: Email
Address:
Direct Telephone: ( ) -
I hereby affirm that I am the owner of the below referenced credit card and that my name is listed on the front of the credit card.
I hereby authorize Auction Gallery of the Palm Beaches to charge my credit card (listed below)
in the amount of $__________________ for payment of goods purchased at auction.
_________________________________
Account Holder Signature
CREDIT CARD INFORMATION
Credit Card Type: □ MasterCard □ Visa □ American Express □ Discover Card
Number: ________________________________________________________________
Expiration Month: ______ Expiration Year: _____ Security Code: ____________
Cardholder Signature X Date / /
Security Code:
................
................
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