Credit Card Payment Authorization Template 2
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CREDIT CARD PAYMENT AUTHORIZATION
Date: ______________
Organization Name: ______________________________________________
CCC Customer Account Number:________________________________________________
Cardholder’s Name: ___________________________________
Phone Number: _____________________ Cardholder’s Signature: ______________________
Name of person placing order (if different from above): ________________________________
Credit Card (circle one)

MasterCard

VISA

American Express

Credit Card #: _______________________________________Expiration Date: _________
In Payment of:
Invoice number

Amount Due

_______________________ ____________
_______________________ ____________
_______________________ ____________
_______________________ ____________
_______________________ ____________
Total to charge: $_________________
Special Handling Instructions:
Charge total amount due
Charge each invoice individually
Other Special Instructions:___________________________________________________