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Halski Systems
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Credit Card Authorization
Date
Business Legal Name
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Name of person granting permission to charge credit card
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First
Last
Title
Email
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Invoice number(s)
*
Enter the invoice(s) you are paying
Amount of payment
Total to be paid this transaction
Authorization for:
*
Single Payment
Recurring Payments
If recurring is selected your credit card will be billed monthly for the amount of the monthly invoice
Card Type
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Visa
MasterCard
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Name on card
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Last
Billing Address
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Street Address
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Credit card number
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no spaces or dashes
Expiration Date
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CVV security code
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Authorization to charge credit card
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Click for authorization
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
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