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
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 agree to voice-only authorization
I want to set up an automatic charge every month until I call you to cancel,
on my 2nd and all future bills!
Automatic monthly charge, 10% discount
I agree to charge my credit card 1 time for this amount
After you fill out this form, please
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.