Credit Card Authorization Form

Please complete all fields.This Credit Card Authorization Form will remain in full force and effect until
competen-sea America, Inc. has received written notification from the Cardholder (or either of us) of its termination.
It is also the Cardholder’s obligation to notify competen-sea America, Inc. in writing of any changes in the credit
card information, address, credit card number, CVC/CVV codes, or expiration date.

Email
This field is for validation purposes and should be left unchanged.
Company Name*
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Card Holder Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Signature*
I, _____________________________________, certify that I am the authorized holder and signer of the credit card referenced above and that all information is complete and accurate. I hereby authorize competen-sea America, Inc. to charge my credit card for agreed upon purchases.
*
- I understand that my information will be saved to file for future transactions on my account.
Date
MM slash DD slash YYYY
Consent
I agree to the privacy policy.

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