Music
Masters Entertainment, Inc
One
Time Credit Card Payment Authorization Form
Sign and complete this form to
authorize Music Masters Entertainment, Inc to make a one time debit to your
credit card listed below.
By signing this form you give us
permission to debit your account for the amount indicated on or after the
indicated date. This is permission for a single transaction only, and does not
provide authorization for any additional unrelated debits or credits to your
account.
Please complete the information
below:
I ________________________ authorizeMusic Masters Entertainment, Inc to charge my credit card (full name) account
indicated below for _____________ on or after ___________________. This payment
is for (amount) _______ (date) ______________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
(description
of goods/services)
Billing Address
___________________________ Phone# ______________________
City,
State, Zip ____________________________ Email ________________________
Account Type: Visa MasterCard AMEX
Discover (circle one)
Cardholder Name
_________________________________________________
Account Number
_________________________________________________
Expiration Date ____________
CVV2 (3 digit number on back of
Visa/MC, 4 digits on front of AMEX) ______
SIGNATURE __________________________DATE
_________________________
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.