Credit Card Authorization Credit Card Authorization If you would like to pay by credit card, you can complete and return this form once your order is ready. If you do not wish to complete this form electronically you can download it by Clicking Here. Do you want your credit card information kept on file?* Yes No Would you like a receipt e-mailed?* Yes No Date* Customer Name* First Last Name On Card* First Middle Last Credit Card Billing Address (as it appears on statement)* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Invoice Number (s)*Amount to Charge (plus 3.5% fee)*Person Authorizing Purchase:* First Last Email* Phone*By signing below, I am authorizing the charge as stated above to the credit card listed below:Electronic SignatureSignature*Date* Credit Card Number*Expiration Date*Security Code (3 digits on back)*CommentsThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle AJAX powered Gravity Forms.