Square Credit Card Authorization Form

Credit Card Authorization Form
Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will
remain in effect until cancelled.
Credit Card Information
Card Type:

MasterCardVISADiscoverAMEXOther
Cardholder Name (as shown on card):
Expiration Date (mm/yy):

MonthDayYear
Date
I, {cardholdername} authorize Autism Spectrum Mandate Services 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.
Customer Signature
Date

MonthDayYear
Date
Should be Empty:

Credit Card Authorization Form