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One (1) Time Credit Card Payment Authorization Form

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A one (1) time credit card payment authorization form gives a merchant the right to charge a customer’s credit card a single time without the physical card being present. Obtaining the customer’s approval with the form gives the merchant protection in the event a chargeback is initiated.

The following information is needed to complete the form in full:

  • Full name and address of the cardholder;
  • Merchant name;
  • Amount of charge ($);
  • Date (mm/dd/yyyy) that the charge will occur;
  • Card type used (VISA, Discover, etc.);
  • Card number (#), expiration date, CVV, and ZIP code; and
  • Cardholder signature.

Sample

ONE (1) TIME CREDIT CARD AUTHORIZATION

By signing this form, you permit us to charge your credit card 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.

I, [CARDHOLDER NAME], authorize [MERCHANT NAME] to charge my credit card (as indicated below) for $[AMOUNT] on [MM/DD/YYYY].

This payment is for the following: [REASON FOR PAYMENT].

BILLING INFORMATION

Billing Address: [STREET ADDRESS] City, State, ZIP: [CITY, STATE, & ZIP]
Phone #: [CARDHOLDER PHONE] Email: [CARDHOLDER EMAIL]

CREDIT CARD INFORMATION

Card Type: ☐ Mastercard | ☐ VISA | ☐ Discover | ☐ AMEX | ☐ Other [OTHER]
Cardholder Name: [CARDHOLDER NAME]
Card Number (#): [CREDIT CARD #]
Expiration: [MM/YY] CVV: [CVV #] Cardholder ZIP: [ZIP CODE]

CARDHOLDER SIGNATURE

I authorize the above-named merchant to charge the credit card indicated in this authorization form according to the abovementioned terms. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one (1) use only. I certify that I am an authorized user of this credit card and will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

Cardholder Signature: ________________________ Date: [MM/DD/YYYY]

Printed Name: [CARDHOLDER PRINTED NAME]