EFTA00521211.pdf

iTOd australia 216 West 3rd Street Los Angeles, CA 90048 One Time Credit Card Payment Authorization Form Sign and complete this form to authorize Mud Australia to make a one time 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: I authorize Mud Australia to charge my credit card (full name). account indicated below for $ on or after . This payment is for (amount) (date) MUD Australia Porcelain. (description of goods/services) Billing Address Phone# City, State, Zip Email SIGNATURE DATE: 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. EFTA00521211