Credit Card Authorization Form

(Single Transaction Only)


I, _________________________________ hereby authorize CMS Life Maintenance in California to charge


the amount of US$ _________________on credit card # __________________________________

with the expiration date of __________/ ______/ ________.

By signing this form, I agree with all terms and conditions of the sale / order which I have made over the phone, by fax or via the internet. I understand that this information will be used for purposes of verification with the credit card issuer / processors to prevent fraudulent usage. And also as the credit card holder, I hereby authorize receipt of merchandise at the shipping address below and agree that I will not initiate dispute under No Cardholder Authorization on this charge in the future.

You must attach a legible copy of both sides of the credit card (front and back) and a legible copy of your Driverís License (or other valid photo ID)


Other Credit Card Information

Credit Card Issuer Name: * ___________________  CVC2 Security Code:_________________

Bank Contact Phone #: _______________________  Any Special Program:________________

Company Name (If business card): ________________________

* For Visa, MasterCard and Discover, it is three digits located in the back of the card.

* For American Express, it is four digits located in the corner of the card on the front.



Credit Card Billing Address



State: __________ Zip Code:__________




Requested Shipping Address

Street: ____________________________

City: _______________________________

State: ____________ Zip Code:__________

Telephone: __________________________



Printed Name: _________________________


Signature: ____________________________            Date:______ / _______ / ______



CVV code cannot be stored after initial transaction, prohibited by PCI DDS standards