Credit Card Authorization Form

Cardholder Name

First

Last

Billing Address for Credit Card

Phone Number

Driver License Number

Cardholder Expiration Number

Last 4 digits of your SSN

Date of Birth

Credit Card Number

Expiration Date

CCV (3 Digit Code)

Checkboxes

Visa
MasterCard

Total Amount

Price: $125.00

Payment Confirmation

I, the undersigned, authorize Check Point Chad to charge my processing fee of $125.00 for the DL21SC form to the following credit card account. I represent that the following information is true and correct.

Signature

By entering your name in the box above you agree under penalty of law that all of the above information is true and your are the authorized credit card holder. You are authorizing Check Point Chad to process the payment of $125.00 on your credit card