OIKOS CENTER CREDIT CARD AUTHORIZATION FORM



					OIKOS CENTER CREDIT CARD AUTHORIZATION FORM

CREDIT CARD

Date

04/27/2024

PLEASE READ THIS BEFORE YOU CONTINUE: FORM MUST BE COMPLETED IN FULL, SIGNED BY AN AUTHORIZED USER OF THE CREDIT CARD

Authorized User of the Credit Card *

Name as it appears on credit card

BY EXECUTING THIS

AGREEMENT UNCONDITIONALLY AUTHORIZES TO CHARGE THE FOLLOWING FORM OF PAYMENT:

Credit Card Type *

Credit Card Number *

Expiration Date *

mm/yyyy

Security Code *

For Pay *

As per Invoice or Estimate # *

For the Amount of *

CARDHOLDER'S BILLING ADDRESS

Street *

City *

State *

Zip Code *

Province

Country *

Phone / Mobile *

PHOTOS & AUTHORIZED SIGNARURE

License (Front Picture) *

Select File...

Credit Card (Front Picture) *

Select File...

Credit Card (Back Picture) *

Select File...

Cardholder Authorized Signature *

Reset * By signing above you acknowledge that the credit card provided will automatically be charged for any remaining balance of this order

I CERTIFY THAT THE ABOVE STATEMENTS AND INFORMATION MADE IN THE AGREEMENT ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I ALSO CERTIFY THAT I AM AUTHORIZED TO EFFECT CHARGES TO THE ABOVE CREDIT CARD NUMBER. IN THE CASE OF ANY ISSUES OR DISPUTES CONCERNING THIS TRANSACTION I WILL NOTIFY YOU PROMPTLY TO RECTIFY THE SITUATION PRIOR TO NOTIFYING MY CREDIT CARD COMPANY.

* Required field(s)