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This document is a one-time credit card payment authorization form for TA Solutions, allowing a charge of $196.83 for two panther jerseys on February 19, 2025. The form requires the cardholder's personal and billing information, as well as credit card details. By signing, the cardholder agrees to the transaction and confirms they are an authorized user of the card.

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benny4813940
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143 views1 page

Lofo

This document is a one-time credit card payment authorization form for TA Solutions, allowing a charge of $196.83 for two panther jerseys on February 19, 2025. The form requires the cardholder's personal and billing information, as well as credit card details. By signing, the cardholder agrees to the transaction and confirms they are an authorized user of the card.

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.

Janet M Barlow
I _______________________ TA SOLUTIONS
authorize _________________________ to charge my
(Cardholder’s Full Name) (Merchant’s Name)

196.83
credit card account indicated below for $________________ 02/19/2025
on ________________.
(Amount $) (Date)

panthers Jersey x2
This payment is for ________________________________.
(Description of Goods/Services)

Billing Information
143 North Rd, Salisbury Center
Billing Address ___________________________ 3154299589
Phone # ______________________

NY, 13454
City, State, Zip ___________________________ janetbar48@yahoo.com
Email ________________________

Card Details

☐ Visa ☐ MasterCard ☐ Discover ☐ American Express

Janet M barlow
Cardholder Name ___________________________
4666 0000 2980 3043
Account/CC Number ___________________________
01 26
Expiration Date ____ /____
304
CVV ____
13454
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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