I certify that I am the authorized holder and signer of the credit card referenced above.
I certify that all information above is complete and accurate.
I hereby authorize collection of payment for all charges as indicated above. Charges may not exceed the amount listed above in the “AUTHORIZED AMOUNT” field. I understand this is only for up to this amount during the time period of “DATES OF CHARGES” referenced above. If additional charges are going to be authorized a new form will have to be completed.