CC Authorization Form - Axis International Marketing Ltd.


1800 S. Wolf Rd.    Des Plaines, Illinois 60018   847 297 0744  AXISMKT@AOL.COM

Credit &/or Debit Card Payment Authorization Form

 

Sign and complete this form to authorize Axis International Marketing, Ltd. to make a debit to your credit or debit card listed below. 

By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a transaction to cover the invoice with terms as sent on our invoice number


Please complete the information below:

I

authorize Patents To Retail L.L.C. to charge my credit &/or Debit card, account number, indicated below for

$   on or after

This payment is for

Billing Address  

Phone# Email


Account Type:  

Cardholder Name

Account Number

Expiration Date

CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX)


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.

Leave this empty:

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Signature Certificate
Document name: CC Authorization Form - Axis International Marketing Ltd.
lock iconUnique Document ID: 289d23c749c4637be6f5a3782b3d8e94b051dce5
Timestamp Audit
July 23, 2020 12:11 pm CDTCC Authorization Form - Axis International Marketing Ltd. Uploaded by Andy Berger - andy@123axis.com IP 24.14.121.199