Credit Card Authorization Form

**Worldmedia Travel Group Credit Card Authorization Form**
Cardholder Name

First NameLast Name
Cardholder Email
example@example.com
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ONE (1) TIME CREDIT CARD AUTHORIZATION

By signing this form, you permit us to charge your credit card 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.

I, [CARDHOLDER NAME], authorize Worldmedia Travel Group to charge my credit card (as indicated below) for $[AMOUNT] on [DATE].

This payment is for the following: [REASON FOR PAYMENT].

I authorize Worldmedia Travel Group to charge the credit card indicated in this authorization form according to the above mentioned terms. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one (1) use only. I certify that I am an authorized user of this credit card and will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in the CUSTOMER INFORMATION FORM.
This payment is for the following: [REASON FOR PAYMENT].
Printed Name: [CARDHOLDER PRINTED NAME]
CREDIT CARD INFORMATION

Other
Card Number
Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
CVV#
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Amount
Cardholder Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

**Worldmedia Travel Group Credit Card Authorization Form**

Worldmedia Travel Group Credit Card Authorization Form