Credit Card Authorization Form

Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting us. The information provided is stored across a protected, 256-bit Secure Socket Layer (SSL) connection and will be used for official business only by Spoken Word Children's Therapy.
Name of Child Receiving Therapy

First NameLast Name
Credit Card Information
Credit Card Type:

VISAMASTER CARDDISCOVERAMEXOther
Cardholder Name (as shown on card):

First Name and Middle Initial Last Name
Credit Card Number:
Expiration Date:

MonthDayYear
Cardholder ZIP Code (credit card billing address):
I, blanks authorizeblank to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.
Signature

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Should be Empty:

Credit Card Information