Credit Card Payment Form:
Credit Card Payment Form: If handwriting – please write legibly!
To pay by credit card, please fill in your full name and complete the cardholder information.
Name of Applicant:
Applicant’s Date of Birth:
Day ___ Month ___ Year ______
Credit Card Type (check one): we do not accept American Express
__ Visa __ MasterCard __ Discover/Novus
Name of Cardholder (as it appears on card):
Cardholder Address: (For processing credit card payment only. All materials requested will be sent to the applicant address provided on the appropriate forms.)
________________________________________________________________________________________________________________________________________________
Phone no.: _____________________
If relevant, I would like to( check one) pick up/pay additional shipping
Address: ____________________________________________
*Explanation of Credit Card CVV2 number:
(To be entered below)
Visa and MasterCard: This number is printed on your MasterCard & Visa cards in the signature area of the card. (It is the last 3 digits AFTER the credit card number in the signature area of the card).
Credit Card #:
| | | | | | | | | | | | | | | | |
Expiration Date: ______________ * CVV2 Number ____________________
(See explanation on other side.)
Total Charges U.S. $ ___________________(filled by us)
Cardholder Signature (authorization for payment):
I hereby authorize a charge to my credit card for the total of all services requested on the attached Certification Form, including any fee adjustments in effect as of the date the order is received.
Signature of Authorized Cardholder
................
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