Worksheet for Credit Card Charge
Date: _______________________________________ Name on Card: ___________________________________________________________ Address on Account: ______________________________________________________ ______________________________________________________ ______________________________________________________ Phone Number: _______________________________ Card Type: MC ____ Visa ____
Account Number: ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Expiration Date: ____ ____ / ____ ____ Amount: $ __________________._____
Signature: ____________________________________________________
For office use only: Authorization # __________________________________________ Settle Date: _____________________________________________ Clerk: _________________________________________________
C:\DOCUME~1\HANNUS~1\LOCALS~1\TEMP\Credit Card Information Form.doc