Credit Card Payment Info
Full name and address--as they appear on the credit card bill. 
NAME  ________________________________________________
ADDRESS 1____________________________________________
ADDRESS 2____________________________________________
CITY    ________________________________________________
STATE ________________________________________________
ZIP       ________________________________________________

Card type (MC, Visa, Amex, etc.) 
CARD TYPE ___________________________________________
CARD NO   ____________________________________________
EXPIRATION DATE_____________________________________
SECURITY CODE    _____________________________________
Customer's email address for receipt.

EMAIL     ______________________________________________

Telephone Number  ______________________________________

AUTHORIZED AMOUNT    $ ______________________________

AUTHORIZATION SIGNATURE  ___________________________
KEEP     ________________  DESTROY   ____________________