2. Authorization for Credit Card Use

3. PRINT AND COMPLETE THIS AUTHORIZATION AND RETURN
PRINT AND COMPLETE THIS AUTHORIZATION AND RETURN.  All information will remain confidential

5. Name on Card: ___________________________________________

7. Billing Address: ___________________________________________

8. ___________________________________________

10. Credit Card Type: _____ Visa _____ Mastercard ____ Discover _____ AmEx

11. Credit Card Number: ___________________________________________

12. Expiration Date: ___________________________________________

13. Card Identification Number: ______ (last 3 digits located on the back of the credit card)

14. Amount to Charge: $ ________________ (USD)

15. I authorize ___________________________ to charge the amount listed above to the credit card provided herein. I agree to pay for this purchase in accordance with the issuing bank cardholder agreement.

17. Cardholder – Please Sign and Date

19. Signature: ___________________________________________

20. Date: ___________________________________________

21. Print Name: ___________________________________________

22. Return the completed and signed form to the following: