SAN DIEGO COUNTRY ESTATES ASSOCIATON
24157 San Vicente Road
Ramona, CA 92065
Credit Card Authorization Form
Contact Information
Name (Please print name as it appears on card):
Billing Address:
________________________________________________________________________
________________________________________________________________________
Credit Card Type (check one): ___Visa ___MasterCard ___AMEX
Credit Card Number: ______________________________________________________
Security code (on back of card): _______
Expiration Date (Month/Year): ______________________________________________
Email: _____________________________________ Phone______________________
I authorize San Diego Country Estates Assn. to charge my credit card USD ___________
for payment. Please Check: One Time Charge Only _______
Recurring Monthly _______
Signature Date
This form must be filled out completely. Please make sure to indicate the amount to be
charged to your credit card.
Please notify us in writing of any changes to your credit card account or discontinue
recurring charges.
Please fax form to 760-788-6115.