CC Authorization Form - Patents to Retail Partners LLC


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 Patents To Retail, L.L.C. 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 - Patents to Retail Partners LLC
lock iconUnique Document ID: b8537a7e410b91faff883f1762d2a477ceac035d
Timestamp Audit
July 23, 2020 11:27 am CDTCC Authorization Form - Patents to Retail Partners LLC Uploaded by Andy Berger - andy@123axis.com IP 24.14.121.199