Credit Card Authorization Form Type of Credit Card(*) VisaMasterCardDiscover CardOther Invalid Input If you prefer to give us your credit card number over the phone,place an X in the form below and call us at 855-772-3782. Credit Card Number: (*) Invalid Input Expiration Date(*) Invalid Input Three Digit Security Code on Back of Credit Card(*) Invalid Input Amount Authorized to Charge(*) Enter Amount to Be Charged Charge is for: (i.e. Editing, Publishing, Printing, etc.) (*) Invalid Input Customer Name:(*) Invalid Input Company: Invalid Input Billing Address:(*) Invalid Input City, State, Zip(*) Invalid Input Name on Card:(*) Invalid Input Authorized On:(*) Invalid Input Authorized By:(*) Invalid Input With my signature below, I hereby authorize Certa Publishing to maintain a record of my credit card information and to charge my credit card for applicable sales tax, freight and/or printing overage variance of up to 5% as stated in the printing agreement as ordered by me, either in writing, by telephone, fax, or email. Signature: (*) Invalid Input For Security, Please Complete This Captcha(*) Invalid Input Click Here to Authorize
