Payment Authorization Form

Payment Authorization Form
Sign and complete this form to authorize Xclusive U Era Hair Collection LLC to make a one-time payment to your credit/debit card listed below.

By signing this form, you give us permission to charge your account indicated on or after the indicated date. This is permission to a single transaction ONLY, and does NOT provide authorization for any additional unrelated charges to your account.
Cardholder's Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Billing Information*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload Your Identity Card*

Cancelof
I authorize the above named business to charge the credit/debit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the products described on Xclusive U Era Hair Collection LLC official website, for the amount indicated at check out only, and is valid for one time use only.

I certify that I am an authorized user of this credit/debit card and that I will not dispute the payment with my credit/debit card company; so long as the transaction corresponds to the terms indicated in this form.
Signature*

Powered by Jotform SignClear
Should be Empty: