Marvelous Style by Marla
Credit Card Authorization Form
Please complete this form and e-mail it to Marla Smith at [email protected] . All requested information is required.
I _____[your name]______________________________________________ authorize Marvelous Style by Marla to bill the credit card
listed below as specified. I agree to pay all charges as specified in the proposal in full as agreed.
Amount:
$_______________
Frequency: Three Times for a total of $________________
Initial payment charged upon signing of contract, second payment run at 30 days, and third payment run at 60 days.
Start Billing on
___________________
End Billing: _____________________
Credit Cards we accept: Visa, MasterCard, and Discover.
Credit Card # ______________________________________Expiration Date: _____________
Name as it appears on card: ____ __________________________________________________
Billing address for card: ___ ___________________________________
City: __McMinnville____________________ State: _______ _______ Zip Code: _________________
3 Digit Code (CVV) ________ (from signature line on back of card)
I agree to these terms and will pay as agreed:
Client Name
________________________________________________
(client signature)
________________________________________________
(print name)
___________________________________
(date)