One Time Credit Card Payment Authorization Form Please complete

25552 La Paz Road, Laguna Hills, CA 92653  Tel: (949) 586-6800 Fax: (949) 586-0382  www.ocrealtors.org

One Time Credit Card Payment Authorization Form

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.

Please complete the information below:

Account Type: Visa

Dues and/or Fees

Street

City, State, Zip

Phone Number

Store purchase

Revised 07/24/20

Advertising

Mastercard Amex Discover

Cardholder Name

Account Number

Expiration Date

Amount to be Charged:

Goods and Services provided:

SIGNATURE OF THE CARDHOLDER DATE

Billing Address:

CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX)

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.