One Time Credit Card Payment Authorization Form All Information Will Remain Confidential I authorize Uvoice USA, LLC to charge my credit card account in the amount and on the date indicated below: Full Name* Amount I understand that this credit card service is provided as an alternative payment option.Business Name* Phone*Email* CC Information:Account Type Visa MasterCard Amex Discover Cardholder Name* Card Number* Expiration Date* CVV Code* (3 digit number on back of Visa/MC, 4 digits on front of AMEX)Billing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Consent:Authorized Consent* I agree to the submission of my CC information.I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I certify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.Customer Name* Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
