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 Address:  

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: