OIKOS CENTER CREDIT CARD AUTHORIZATION FORM
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CREDIT CARD
Date 05/29/2024
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 *
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 *
Email  
PHOTOS & AUTHORIZED SIGNARURE
License (Front Picture) *
Select File...
Credit Card (Front Picture) *
Select File...
Credit Card (Back Picture) *
Select File...
Cardholder Authorized Signature *

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* By signing above you acknowledge that the credit card provided will automatically be charged for any remaining balance of this order
*
* Required field(s)
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