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Credit Card Payment Authorization
Complete the form below to authorize a one-time charge.
Cardholder Name
Amount (USD)
Billing Address
City, State, Zip
Phone Number
Email
Payment Date
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Card Type
Visa
Mastercard
Amex
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Card Number
Expiration
CVV
Signature (Type full name)
Date
Upload Credit Card Front Copy
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Accepted formats: JPG, PNG, PDF
Upload Credit Card Back Copy
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Accepted formats: JPG, PNG, PDF
Submit Authorization
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