One Time Credit Card Authorization Form

Complete and sign this form to authorize New Material Culture Inc. to make a onetime debit to your credit card listed below. By signing and submitting this form you give us permission to debit your account for the amount you indicate on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any unrelated debits or credits to your account.

Please complete the information below:

Name(Required)

The name of the person authorizing New Material Culture Inc. to charge your credit card in the amount specified below.

Amount to be charged(Required)

The amount you authorize to be debited from your account.

Auction Invoice #(Required)

The Material Culture Auction invoice #

Date(Required)

The earliest date you authorize your card to be debited in the amount you specified above.

Billing Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Card Information

Cardholder Name(Required)

Card Number(Required)

Exp. Month(Required)

Exp. Year(Required)

Security Code(Required)

Signature/Consent

Authorization(Required)

By checking (ON) this checkbox, I authorize the above named business to charge the credit card indicated in this authorization form accounting to the terms and conditions of the sale and the outlined agreement above. This payment authorization is for the invoice described above, for the amount indicated above only and is valid for one-time use. By checking this form's checkbox, I also 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.

Signature(Required)

Type your name

Date(Required)