Fillable Printable Credit Card Information Form Template

Credit Card Information Form Template

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CREDIT CARD INFORMATION

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If you want to pay by credit card, please fill out the form below and submit it along with your completed Application form to IERF. NOTE: No

refunds will be issued once an application has been submitted. If you have already submitted your completed Application form to IERF

and did not include the credit card information, or if you wish to make an additional payment, please mail the form to IERF (you can also fax

the form directly to 310.342.7086; be sure to include your file number as well, if applicable). We recommend that you fill the form out online,

print it, sign and date it, and mail it along with the appropriate documents to our address below. Alternatively, you can print the form and fill it

out by hand.

Please note that IERF only accepts Visa or MasterCard

For Office Use Only

IERF File Number: ________________________________

Date:

_______ / _______ / ________

Fees: _________________________________

Authorization _________________________________

IERF File Number: (if applicable)

Name of Cardholder: (as it appears on credit card: first, middle, last)

Name of Applicant: (if different from above)

Billing Address:

Number street apt. #

city state zip/postal code country

I authorize IERF to charge my: (check one)  Visa  MasterCard in the amount of: $

Credit Card Number: - - -

Security Code or CCV number:

(the 3-digit number that appears to the right of your card number on the signature strip on the reverse of the card)

Expiration Date: (month/year) /

Signature of Cardholder: (required) Date:

The signatory authorizes IERF to charge the amount for the requested services in U.S. dollars and agrees to be bound to all Terms and

Conditions (including that all fees are non-refundable) as stated in the IERF Application Form.