Credit Card Authorization Form NH

Authorization for Credit Card Use

PRINT AND COMPLETE THIS AUTHORIZATION AND RETURN. 
All information will remain confidential

Name on Card:                  ___________________________________________ 

Billing Address:                    ___________________________________________

                                                ___________________________________________

Phone Number:                  ___________________________________________

Credit Card Type:              _____ Visa     _____ Mastercard 

Credit Card Number:       ___________________________________________
 

Expiration Date:                 ___________________________________________

Card Identification Number:  ______   (last 3 digits located on the back of the credit card)

Amount to Charge:  $  ________________ (USD)

Please use these funds to pay for this car(s)__________________________________________ 

I authorize Capital Auto Auction to charge the amount listed above to the credit card provided herein. I agree to pay for this purchase in accordance with the issuing bank cardholder agreement.

Cardholder – Please Sign and Date

Signature:                             ___________________________________________

Print Name:                          ___________________________________________

Date:                                      ___________________________________________

 
Return the completed and signed form to the following:

Fax:  603-622-9063

OR

Email: [email protected]