One (1) Time Credit Card Payment
Authorization
DIRECTATT LLC
Sign and complete this form to authorize ________________ to make a one-time
charge to your credit 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 single transaction only,
and does not provide authorization for any additional unrelated debits or credits to your
account.
Joyce L Marker
I _______________________ DIRECTATT LLC
authorize _________________________ to charge my
(Cardholder’s Full Name) (Merchant’s Name)
123
credit card account indicated below for $________________ 09/19/2024
on ________________.
(Amount $) (Date)
This payment is for ________________________________.
A CUSTOMIZED TABLE CLOTH WITH MY FAMILY PICTURE
(Description of Goods/Services)
Billing Information
PO BOX 775
Billing Address ___________________________ 2407317979
Phone # ______________________
POLK CITY
City, State, Zip ___________________________ joyce.maker@excite.com
Email ________________________
Card Details
☐ Visa ☐ MasterCard ☐ Discover ☐ American Express
JOYCE L MAKER
Cardholder Name ___________________________
6011 0146 5863 3529
Account/CC Number ___________________________
29
Expiration Date ____ /____
06
CVV ____
526
33868
Zip Code _______
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 (1) 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.
SIGNATURE ___________________________ 09/19/2024
DATE _____________________
(cardholder)
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