Credit Card Authorization
 
File Reference Number
Beneficiary
 
Type of Credit Card*
Authorized Amount Charge*
Name on Credit Card*
Card Number*
Expiration Date (MM/YYYY)*
Security Code (on back of card)*
Billing Address on Card*
Billing City, State, & Zip Code*


I hereby expressly authorize 1st 1's 2 Leap to enter a charge against the credit card more fully described above. I represent to 1st 1's 2 Leap that I have complete authority to use and sign for charges made on this credit card account. I am also making this charge willingly and
under no coercion.

I understand and acknowledge that this charge is being make to absolve a debt owed to the beneficiary identified above. I understand that no purchase of goods or services, either current or in the future, is being made or promised. It has been represented to me that this authorization is for a one time only unless otherwise instructed. I understand and acknowlege that the charge may include a service charge and that the amount charged to my credit card may not fully accuse to the beneficiary above; however at no time will the accrual to the beneficiary be less than 95% of the authorized amount. I ackowledge that a representative of 1st 1's 2 Leap has fully explained to me.
Name*
Email*
Date*


I approve the above charge and agree to all statements on this authorization form.