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Credit Card Authorization Form
Customer Information
Customer Name
(*)
Customer Business Name (
If Applicable
)
Customer Address
(*)
Customer Phone
(*)
Customer Email
(*)
Customer Contact Name
(*)
Credit Card Information
Cardholder Name
(*)
Credit Card Number
(*)
Credit Card Expiration
(*)
Credit Card Security (
Last 3 Digits
)
(*)
Credit Card Zip Code
(*)
Terms & Conditions
I (we) hereby authorize Allpro Technology LLC (THE COMPANY) to initiate entries to/from my (our) credit card using the financial information entered, and, if necessary, initiate adjustments for any transactions credited/debited in error. This authority will remain in effect until THE COMPANY is notified by me (us) in writing to cancel it in such time as to afford THE COMPANY and THE FINANCIAL INSTITUTION a reasonable opportunity to act on it. I agree to notify, in writing, of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. Furthermore, I certify that I am an authorized user of this credit card.
BY CHECKING THE "I ACCEPT THE TERMS & CONDITIONS ABOVE" CHECKBOX AND ENTERING MY NAME BELOW, I CONFIRM THAT I HAVE READ, UNDERSTAND, AND AGREE TO BE BOUND BY THESE TERMS AND CONDITIONS.
I ACCEPT THE TERMS & CONDITIONS ABOVE
(*)
Name of authorized representative:
(*)
Today's Date:
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