PERMANENT CREDIT CARD AUTHORIZATION INFORMATION - DOC

							                         CREDIT CARD “ON FILE” AUTHORIZATION FORM

IOGLB is authorized to maintain credit card payment information in our confidential files. This form is being
provided for you to supply IOGLB this information for the upcoming license year.

Your signature authorizes us to review this information and deduct fees from the credit card below, when you
sign the applicable application.


_______________________________________                      _______________
Business Name                                                License #


_______________________________________                      _______________
Outfitter/Designated Agent Signature                         Date Signed


_______________________________________                      _______________
Printed Name                                                 License #

Outfitter applications, Designated Agent applications, and Guide application forms include a box that you must
sign to authorize use of this credit card for the license fee(s), verbal authorization will not be accepted at any
time.

                       *******We only accept Mastercard or Visa at this time*******


Cardholder Name (as imprinted on credit card)


Cardholder Signature

Card Number #

Expiration Date

If anyone other than the cardholder is authorized to use this credit card, please have him or her print and
sign his or her name:


_______________________________________                      _______________
Signature                                                    Date Signed


_______________________________________
Printed Name


Cardholder Authorizing signature