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Credit Card Authorization Form

 Credit Card Authorization Form

 

 

I, _________________________________________________________ , on behalf of

                                                                (PRINT NAME)

 

___________________________________________________________________________

                                                                        (PRINT COMPANY NAME)

 

hereby authorize KENIAN to charge my credit card account for payment of my order.

 VISA                         MasterCard                     American Express

Credit Card Number: __________________________________________________________

Expiration Date: ________ /__________    VID Code: ______________

Credit Card Billing Address:

Name on Credit Card: _________________________________________________________

Street:  _______________________________________________________________

City:  __________________________________________  State:  ________________

Zip Code: ___________ - _________ Country: (if not US) _______________________

Telephone: (        ) _______- ______________

 

_____________________________________________                  _____/_____/______

Cardholder's Signature                                                                                          Date

 

As the credit card holder, I also authorize KENIAN to charge my credit card for future purchases approved by me.

 

Authorization Valid Until: _______ / ________            Initial Here: _________________

 
Your completion of this authorization form helps us to protect you, our valued customers, from credit card fraud.  KENIAN will keep all information entered on this form strictly confidential.