Credit Card Authorization

I, *

(Print Name) hereby authorize Vivid Leds, Inc. to initiate a withdrawal against my account using the card number listed below. By signing this form, I give Vivid Leds, Inc. permission to debit my account for the amount in full on or after the indicated date. This transaction is for a single debit only, and does not provide authorization for any additional unrelated debits or credits to my account unless I accept to keep the card on file

Card Type *

Visa
Mastercard
Discover

Credit Card Number *

Expiration Date: *

Security Code: *

Company Name: *

Cardholder's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

PO #:

Invoice #:

Total amount to be charged: *

(USD) United States Dollars

If you would like us to keep your credit card on file for future transactions, please accept: *

Accepted
Rejected

Ongoing Payment Authorization

I authorize Vivid Leds, Inc. to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization for the amount indicated above is for the product confirmed in the PO and Invoice and is valid for one time use only unless noted. I certify that I am an authorized user of this credit card and I will not dispute the payment with my credit card company for any reason. I acknowledge the products ordered as listed on the PO and Invoice are tied to this payment and cannot be revised or canceled after the payment has been charged.

Authorized Signature: *

First

Last

entering your name here acts as a signature

Date / Time *

Date

Time

Credit Card Authorization

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Phone

Email

Address

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