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