Docstoc

Credit Card Processing Authorization Insurance Source Group, Inc CREDIT CARD AUTHORIZATION FORM

Document Sample
Credit Card Processing Authorization Insurance Source Group, Inc CREDIT CARD AUTHORIZATION FORM Powered By Docstoc
					                                           Credit Card Processing Authorization
                                            Insurance Source Group, Inc.
                                                            550 N. Bumby Av
                                                                Suite 220
                                                           Orlando, FL 32803
                                                              407-740-5592
                                                      www.insurancesourcegroup.com


                              CREDIT CARD AUTHORIZATION FORM
Card Holder’s Name:
                                                                                     Date:
(As it appears on the card)

Credit Card Number:

Billing Address where the card is issued

Three Digit Security code on the back of your card:

Expiration Date:

                                               VISA                        MASTERCARD

                                                                   Amex


              I,                                     , give authorization to Insurance
              Source Group, Inc. (ISG) to charge my credit card account given above for
              the following payments.

                                              Please write the payment amount below

                                Description                                                            Amount

Automobile: Extended Non-Owned Auto with Taxes and Fees                          Annual      $461.54
MEPA Association Dues                                                            Annual      $10.00

Total Annual                                                                                 $471.54

2-Pay Plan 50% at Policy Inception – 50% in 30 Days                                          $235.77

                                                                                             $
                                                                                             Waived for MEPA
Service Fee (3% of total premium)
                                                                                             Members
TOTAL AMOUNT:                                                                                $235.77


                By signing below, cardholder acknowledges receipt of services described above in the
                amount of the total shown hereon and agrees to perform the obligations set forth in the
                Cardholder’s agreement with the issuer.


           Cardholder’s Signature: X            _________________________________________________________

				
DOCUMENT INFO