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One-Time Credit Card Payment Authorization Form

A one-time credit card authorization form allows a merchant to process a credit card payment during a single transaction without the card being present. The merchant accepting the payment will usually require the cardholder's name, billing address, zip code, and the card's three-digit security code.
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How to Write

Step 1 – Download the document – Submit:

  • The name of the authorized individual
  • Cardholder’s full name
  • Merchant’s name
  • Enter the amount authorized to be charged to the credit card amount
  • Provide the date in which the authorized individual will have permission to make the transaction in mm/dd/yyyy format
  • Submit a description of the goods and/or services to be purchased

Step 2 – Billing Information – Provide the following information:

  • The cardholder’s billing address
  • City, State, Zip Code
  • Telephone number
  • Email address

Step 3 – Card Details –

  • Check the box, indicating the credit card or debit card that shall be used for purchase
  • Enter the cardholder’s name
  • Account or Credit Card number
  • Expiration Date, located on the front of the card in mm/yy format or mm/yyyy for some
  • CVV security code – 3 or 4 digits, located on the back of the card
  • Enter the zip code to the billing address that is connected to the credit card information

Step 4 – Cardholder’s Signature –

  • Once the cardholder’s information has been completed, they must carefully review the authorization statement
  • If in agreement, the cardholder must provide their signature
  • Date of signature in mm/dd/yyyy format