Visa
Dues and/ or fees
Mastercard
Store purchase
Amex Discover
Advertising
Card Type:
Cardholder Name
Street
Card Number
City, State, Zip
Expiration Date
Phone Number
CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX)
Email
Amount to be Charged:
Billing Address:
SIGNATURE OF THE CARDHOLDER DATE
Goods and Services provided
Sign and complete this form to authorize the Orange County REALTORS® to make a one time debit to your credit card
listed below.
By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date.
This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or
credits to your account.
I authorize the above named business to charge the credit card indicated in this authorization form according to
the terms outlined above. This payment authorization is for the goods/services described above, for the amount
indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and
that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms
indicated in this form.
25552 La Paz Road, Laguna Hills, CA 92653 ★ Tel: (949) 586-6800 ★ Fax: (949) 586-0382 ★ www.ocrealtors.org
Revised 06/01/21
One Time Credit Card Payment Authorization Form
Please complete the information below:
$
