NCLEX Service fee credit card authorization
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Credit Card Authorization Form
Sign and complete this form to authorize Apply Ready License Processing Inc. 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. Note: The amount charged to your credit card will be reflected as a charge from
WWW.APPLYREADY.COM
on your billing statement.
I
[
Cardholder Name]
(name on credit card), authorize Apply Ready License Processing Inc. to charge my credit card account indicated below for
[Amount]
(amount)
. on
[Date]
(date).
Type of Payment:
[Payment Type]
(NCLEX Service Fee)
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 charge 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 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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