Credit Card Payment Authorization Form

MKA Credit Card Payment Authorization Form


Please provide the following information for your company’s credit card that will be charged via Mark Kamin & Associates' credit card payment's service, per the terms of the contract.


Company Name:    

Name On Credit Card:   

Credit Card Number:    

Expiration Date (MM/YYYY):    

Security Code:    
(Code is 3 digits on the back of Visa/MC/Discover, or 4 digits on front of AMEX)

Billing Zip Code:    

Billing Phone Number:    



I,   , authorize Mark Kamin & Associates, Inc. to charge the credit card provided above for the payment amounts due on the dates stated in the terms of our companies' contract.


Date of Signature:                            



Leave this empty:

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Signature Certificate
Document name: Credit Card Payment Authorization Form
lock iconUnique Document ID: e25367b4946886d4c6567210648e76d92634b781
Timestamp Audit
February 14, 2023 10:44 pm CDTCredit Card Payment Authorization Form Uploaded by Matthew Woodhill - IP