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One Time Credit Card Payment Authorization Form

Sign and complete this form to authorize Outlet Auto Group to make a one-time debit to your Credit Card listed below

By signing this form, you gave us permission to debit your account 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

Please Complete the information below:

Authorize Outlet Auto Group to charge my credit card account indicated below for

on or after
This payment is for
Billing Address
City, State, Zip
Account Type
VisaMaster CardAMEXDiscover

Cardholders Name
Account Number
Epiration Date
"I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the good/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form ".

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