Credit Card Authorization Form

After you complete this Authorization Form one of our staff will process the payment with your card as soon as possible.

Name on Card

First Name

Last Name

Credit Card Number

Billing Address

Address Line 1/City/State/ZipCode

CCD/CVV

Expiration Date

Be sure you enter the month and year. The Day is not important.

MM

DD

YYYY

Amount to Authorize

$

Type

Enter your Credit Card type

Authorize

Authorize Visual Media Group LLC to charge the following items/invoices to my credit card. Applicable tax may not be included in the stated dollar amount. These charges will be added if applicable. Being the cardholder or Corporate Officer, by signing below I understand and agree to the terms set forth in this agreement, agree to pay, and specifcally authorize to charge my credit card, for the services provided. I further agree that in the event my credit card becomes invalid, I will provide a new valid credit card upon request, to be charged for the payment of any outstanding balances owed.

Yes

Name of The Event or Company for Reference

Event Date

Invoice Number

Enter you invoice number