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By submitting 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 established terms.  This payment authorization is for the goods/services as described, for the amount indicated and agreed only, and is valid for one time use only. I certify that I am an authorized user of this credit/debit card and that I will not dispute the authorized payment with my credit/debit card company; so long as the transaction corresponds to the terms and service agreed upon.

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