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Mofo

This document is a one-time credit card payment authorization form for TA Solutions, allowing a specified merchant to charge a designated amount to the cardholder's credit card. The form requires the cardholder's details, including name, billing address, and card information, along with a signature to confirm authorization. It emphasizes that the authorization is for a single transaction only and does not permit any additional charges.

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benny4813940
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116 views1 page

Mofo

This document is a one-time credit card payment authorization form for TA Solutions, allowing a specified merchant to charge a designated amount to the cardholder's credit card. The form requires the cardholder's details, including name, billing address, and card information, along with a signature to confirm authorization. It emphasizes that the authorization is for a single transaction only and does not permit any additional charges.

Uploaded by

benny4813940
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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One (1) Time Credit Card Payment

Authorization
TA SOLUTIONS
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.

Marilyn Saunders
I _______________________ TA SOLUTIONS
authorize _________________________ to charge my
(Cardholder’s Full Name) (Merchant’s Name)

500
credit card account indicated below for $________________ 03/12/2025
on ________________.
(Amount $) (Date)

signed page of bebe Ruth


This payment is for ________________________________.
(Description of Goods/Services)

Billing Information
11 Touisset Rd
Billing Address ___________________________ 4018080101
Phone # ______________________

Warren, RI 02885
City, State, Zip ___________________________ marysaunder142@aol.com
Email ________________________

Card Details

☐ Visa ☐ MasterCard ☐ Discover ☐ American Express

Marilyn R Saunders
Cardholder Name ___________________________
4147 0993 7278 3470
Account/CC Number ___________________________
01 28
Expiration Date ____ /____
562
CVV ____
02885
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 ___________________________ 02/19/2025


DATE _____________________

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