Credit Card Payment By Fax

Credit Card Authorization (by fax) Credit Card Payment by fax Please complete all fields.  You may cancel this authorization at any time by emailing us. This authorization will remain in effect until cancelled. Card Type:   ☐ MasterCard  ☐ VISA  ☐ Discover  ☐ AMEX Cardholder Name (as shown on card): ____________________________________________ Card Number:  ______________________________________________________________ Expiration […]