Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled. This information will be processed by Square, Inc. and may be stored in the United States and other countries.

I, , authorize to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

Card Type:MasterCardVISADiscoverAMEXOther

Other Card Type (if any):

Cardholder Name (as shown on card):

Last 4 digits of Card Number:

Expiration Date (mm/yy):

Cardholder Postal Code (from credit card billing address):

Customer Signature:

Customer Email:

Date: