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Credit Card Authorization Form

(Credit card MUST be a company card or the personal card of a principal, officer or owner of the company.)

Client / Company Name:

Credit Card Type: Visa Mastercard Discover American Express

Cardholder Type: Company / Corporate Card Personal Card

Cardholder Name:

Cardholder Title:

Card Number: Expiration Date:

CVV Code:

Billing Address 1:

Billing Address 2:

City: State: Zip Code:

Cardholder Phone Number:

Bank Phone Number:

I authorize Laser Stop LLC, to charge purchases of products and services to the above credit card for the named account listed above. I also authorize Laser Stop LLC to make approved purchases with this card from other vendors on our behalf. This authorization will remain in effect until Laser Stop LLC receives written notice of cancellation, or at the discretion of Laser Stop LLC to request an update. I acknowledge all information contained herein is accurate.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

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Timestamp

Audit

January 5, 2021 10:22 am MDT

Credit Card Authorization Form Uploaded by Scott King - scott@laserstopllc.com IP 67.182.254.50