Credit Card Authorisation Form
Please complete all fields. You may cancel this authorisation at any time by contacting us. This authorisation will
remain in effect until cancelled.
Credit Card Information
Card Type: ☐ MasterCard ☐ VISA ☐ AMEX
☐ Other ___________________________________________
Cardholder Name (as shown on card): ___________________________________________
Last 4 digits of Card Number: ___________________________________________
Expiry Date (mm/yy): ___________________________________________
I, _______________________________, authorise __________________________________ to charge
my credit card above for agreed upon purchases. I understand that my information will be saved to file for
future transactions on my account.
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