Credit Card Authorization Form

Credit Card Information

Card Type: ☐ MasterCard ☐ VISA ☐ Discover ☐ AMEX

☐ Other ___________________________________________

Cardholder Name (as shown on card): ___________________________________________

Last 4 digits of Card Number: ___________________________________________

Expiration Date (mm/yy): ___________________________________________

Cardholder ZIP Code (from credit card billing address): _____________________________________

I, _______________________________, authorize __________________________________ to charge

my credit card above for agreed upon purchases. I understand that my information will be saved to file for

future transactions on my account.

_______________________________________

Customer Signature

_______________________________________

Date

Sorghum & Salt, LLC

Please complete all fields.

This authorization form will be valid 9 [nine] months after the signed date.

This form will be encrypted & safely stored for our records.

CREDIT CARD

AUTHORIZATION FORM