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Credit Card Authorization Form
Sign and complete this form to authorize Apply Ready License Processing Inc. to transact, process and make a payment for
CGFNS
using the credit card information listed below.
By signing this form, you authorize Apply Ready to process your
CGFNS
application, prepare and accomplish
CGFNS
paperwork and make payment to
CGFNS
on your behalf using the credit card details you provide on this form. This is authorization for Apply Ready to transact on your behalf with
CGFNS
to use the credit card provided below, and does not provide authorization for any additional unrelated debits or credits to your account. Note: The amount charged to the credit card will be reflected as a charge from
CGFNS
and
NOT
Apply Ready on your billing statement.
I
[
Cardholder Name]
(name on credit card), authorize Apply Ready License Processing Inc. to make payment to
CGFNS
on my behalf using my credit card account indicated below for
[Amount]
(amount)
. on
[Date]
(date).
Type of Payment:
[Payment Type]
(CGFNS)
Branch/Location:
[Location]
(Apply Ready MANILA)
Billing Address of Credit Card:
[Billing Address]
Phone:
[Phone Number]
City, State, Zip:
[City, State, Zip]
Email:
[Email Address]
Answer the following fields based on the
[
Field
]
above.
*
Indicates required field
Cardholder Name:
*
Amount:
*
Date:
*
Payment Type:
*
Location:
*
Billing Address:
*
Phone Number:
*
City, Address, Zip:
*
Email:
*
Account Type:
*
Visa
Mastercard
AMEX
Discover
Cardholder Name:
*
Account Number:
*
Expiration Date:
*
CVV2 (3 OR 4 digit number on back of Visa/MC, 4 digits on front of AMEX):
*
"
I authorize APPLY READY LICENSE PROCESSING INC to transact & make payment to CGFNS on my behalf using the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the 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 understand that the service charge will be from CGFNS and NOT Apply Ready and I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
"
Signature:
*
Max file size: 20MB
Please attach your signature here...
Date:
*
Submit
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