Credit Card Payment Form

1. Credit Card Payment Form Credit Card Payment Form___________, 2011[Customer Name][Address][Phone/Email][Invoice Number]Instructions:Complete this form with credit card billing information and sign where indicated.When complete, submit this form back to “Company XYZ” by faxing it to 1-XXX-XXX-XXXXATTN: Credit Card Billing.To “Company XYZ ”:I hereby authorize “Company XYZ” to charge my credit card for the transaction dated___________, amounting to $ ___________, only.Type of Credit Card: ___________________________________Name on Credit Card: ___________________________________Credit Card Number: ___________________________________Expiration Date: ___________________________________CVV Code: ___________________________________Signature: ___________________________________Date: ___________________________________FOR INTERNAL USE Date Invoice # Amount Charged By Auth Code Notes