Authorize Payment Form

Authorize Payment Form

Please enter the information of the person who the dress is under
Name

First NameLast Name
Email
example@example.com
Last 4 Digits of card being used for over the phone payment*
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized Amount*

prevnext( X )
USDDescription
Please check here

I Authorize Minervas bridal to process payment
Signature

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