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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 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:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

February 14, 2023 10:44 pm CDT

Credit Card Payment Authorization Form Uploaded by Matthew Woodhill - m.woodhill@mka-world.com IP 212.102.46.47