Credit Card Authorization Form

6 Degrees Credit Card Payment Authorization Form

Sign and complete this form to authorize 6 Degrees to make a debit to your credit card listed below.

By signing this form, you give 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:

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E-Mail Address of Advisor

Enter the email address of the advisor that you are working with
Email Address of Advisor*
Full Name*
I authorize 6 Degrees to charge my credit card.
Full Name*
I authorize 6 Degrees to charge my credit card.
Invoice Number
If applicable, please enter the invoice number... Leave blank if you were not provided with an invoice number.

By submitting this form, you acknowledge and agree to abide by all of the terms & conditions included in the denoted invoice.
Amount*
Description of Goods/Services
Billing Address*
Phone Number*
City, State, Zip*
Email
Credit Card Information
Account Type:*
- Visa
- Master Card
- Amex
- Discover
Cardholder Name*
Credit Card Number*
Credit Card Expiration Month*
Credit Card Expiration Year*
CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX)*
Signature*
Date*
MM slash DD slash YYYY
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 goods/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.

6 Degrees Credit Card Payment Authorization Form

Credit Card Information