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.
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:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Credit Card Payment Authorization Form
Agree & Sign