One (1) Time Credit Card Payment Authorization Form

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Updated May 31, 2022

A one (1) time credit card authorization form allows a merchant to process a credit card for a single instance without the card being present. The merchant accepting the payment will usually require the cardholder’s name, billing address, zip code, 3-digit security code (4-digits for American Express), and sometimes the billing phone number. After the information has been entered into the processor’s machine it will either state if the payment was approved or declined.

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