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Credit Card Charge Form

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Vivid Leds, Inc.
4725 Massillon Road.
North Canton, OH 44720.
800-974-3570 Phone/Fax.
Credit Card Payment Authorization Form.
I, ___________________________________________________ hereby authorize Vivid Leds, Inc. to charge my credit card to make a payment to the card number 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 unless accepted below..
Type of Card.
Visa.
MasterCard.
Discover.
American Express.
Credit Card Number: __________________________________________
Expiration Date: __________________________________________
CVV2: __________________________________________
Name of Cardholder: __________________________________________
Credit Card billing address: __________________________________________
City, State, Zip: __________________________________________
Phone #: __________________________________________
Total amount to be charged: _________ (USD) United States Dollars
Authorized Signature of Cardholder ______________________
If you would like us to keep your credit card on file for ongoing payments, please accept:
Ongoing Payment Authorization:
Accepted
Rejected
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 unless accepted above. 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. The items ordered on the PO can not be revised or the transaction cancelled after 3 days of acceptance of the purchase order or after payment is charged.