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:

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Signature Certificate
Document name: Credit Card Payment Authorization Form
lock iconUnique Document ID: 2584e4812588f179fa87a3cb5745a1ce9c9c3ade
Timestamp Audit
February 14, 2023 10:44 pm CDTCredit Card Payment Authorization Form Uploaded by Matthew Woodhill - IP
December 29, 2023 1:04 am CDT Document owner has handed over this document to 2023-12-29 01:04:25 -