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Key Topic #13: Credit Authorization Form

key13 Contractor 20/20 is a service of Multimedia Advertising Service LLC

MULTIMEDIA CREDIT CARD AUTHORIZATION FORM

Please fax this completed form to: (607) 770 6208

Multimedia, 1 Crestmont Rd., Binghamton, NY  13905

 

Company Name_____________________________________________

 

MultiMedia is authorized to verify available funds (authorization only) on the credit card below prior to rendering services.

MultiMedia is further authorized to charge (post authorization) the credit card below after SERVICE has been rendered.

 

PLEASE PRINT ALL INFORMATION CLEARLY

IN READABLE BLOCK LETTERING

 

Amount____________

NOTE: DEBIT CARDS ARE NOT ACCEPTED

CREDIT CARDS ACCEPTED:             VISA   MASTERCARD   AMEX

 

Card# ___________________________________Exp.________________

 

Name appearing on card:_______________________________________

 

Authorized Signature:__________________________________________

 

Relationship of cardholder to business:____________________________

 

Verification# (three digit number on back of card)___________________

 

BILLING ADDRESS VERIFICATION

Street Address_______________________________________________

City ___________________   State________ Zip__________________

Date:____________________

 

Please fax this completed form to: (607)  770 6208

Multimedia, 1 Crestmont Rd., Binghamton, NY  13905