Credit Card Authorization Form
PLEASE FILL OUT ALL THE FIELDS AND FAX OR UPLOAD A SCANNED COPY OF YOUR ID (if we don't have it already). PLEASE DO NOT ENTER YOUR ENTIRE CREDIT CARD NUMBER!! THIS IS NOT A SECURE FORM!!!

This form will NOT charge your card - this is only a digitally signed credit card authorization contract.
__________________________________ I, the Undersigned, authorize a charge to this credit card on the date of this electronic transmission, by Lovings, Inc as specified below. __________________________________
Your phone number *
Your name as it appears on credit card *
Full credit card billing address *
Credit Card Type
Last 4 digits of your credit card *
Expiration date (format: mm/yy) *
Your ID number (Driver's license or passport) *
Last 4 digits of your social security number or country ID number with the name of the country *
ID image of credit card holder (if we don't already have it)
It's OK to charge this credit card in the future using my voice authorization over the phone
I want to set up an automatic charge every month until I call you to cancel,
for 10% discount on my 2nd and all future bills!
I agree to charge my credit card 1 time for this amount
Thanks!
After you fill out this form, please CALL US at (415)386-7697 or (877)386-7697 to give us your full credit card number for the safest and most secure credit card processing.

You can print this page for your records.