Credit Card Authorization Form Mastercard Visa American Express.pdf

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Credit Card Authorization Form  Mastercard Visa American Express.pdf Powered By Docstoc
					                                            2010 Melia Family Fundraiser

                             Credit Card Payment Authorization

   Last Name_______________________ First Name_____________________

   Middle Name or initial _____________ Phone # (____)__________________

                                   Cardholder Information
   Name on the Credit Card
   ___________________________________Donation Amount $________

   Credit Card Billing address _____________________City________ State_____

   □     Mastercard              □     Visa         □    American Express

   Credit Card Number     □□□□-□□□□-□□□□-□□□□
   Expiration date:      □□/□□        *□□□               Card Security Code
 *In the signature box on the back of the card, you should see either the entire 16-digit credit card
   number or just the last four digits followed by a 3-digit code. This 3-digit code is your Card Security
   code. For American Express, enter the 4 digit code here. ___ ___ ___ ____

   As the credit card holder, I hereby authorize Orphan’s Hope Project, Inc. to charge
   the amount of $__________ to my credit card. This is a donation for Orphan’s Hope
   Project, Inc. and will be used for the construction of the new girls’ house at Hogar
   Miguel Magone Orphanage in Guatemala.

   Cardholder Signature ________________________ Date _________, 2010
   Card holder’s e-mail address _______________________
Your completion of this authorization form helps us to protect you, our valued donors, from credit card fraud.
Orphan’s Hope Project, Inc. will keep all information entered on this form strictly confidential.

                                        Orphan’s Hope Project, Inc.
                                 2631 Chapparal Court Pinole, CA. 94564
                                  A non-profit 501(c)3  EIN 26-0261546

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