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:

The name of the person authorizing New Material Culture Inc. to charge your credit card in the amount specified below.
The amount you authorize to be debited from your account.
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)

Card Information

Signature/Consent

Authorization(Required)
Type your name
MM slash DD slash YYYY