Credit Card Authorization Form

Visa and Mastercard Accepted

Your Name (Authorized User)*

Name as imprinted on card*

Address

City, State

Zip Code

Email

Home Phone*

Work Phone*

Debtor ID on Statement

Credit Card Number*

Expiration Date*

Security Code*

Payment Amount($)

Comments



PRIVACY POLICY: We respect and are committed to protecting your privacy. We may collect personally identifiable information when you visit our site. We also automatically receive and record information on our server logs from your browser including your IP address, cookie information and the page(s) you visited. We will only share this information with the clients to whom we are collecting payments on behalf of.
REFUND POLICY: All overpayment refunds will be issued no later than the tenth day of the following month.