Credit Card Payment Authorization

ALLIANCE GRIP AND LIGHTING

One Time Credit Card Payment Authorization Form

Sign and complete this form to authorize ALLIANCE GRIP to make a one time debit to your credit card listed below

By signing this form you give us permission to debit your account 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:

Full name*

Phone Number*

Email*

Billing Address*

City, State, Zip*

Amount($)*

Date *

Description of goods/services*

Production co

Job Name

FINAL INVOICE number

ESTIMATE number

Card Details

Account Type*

Visa

MasterCard

AMEX

Discover

Cardholder Name*

Account Number*

Expiration Date *

Security Code *

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.

Signature*

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