Please sign and complete this form to authorize Hometown Animal Hospital to make a payment on credit card listed below. By signing this form you are authorizing Hometown Animal Hospital to run the credit card provided on or after the date indicated for the payment arrangement listed below. I, authorize Hometown Animal Hospital to charge my credit card for $ On or after .This payment is for Billing Address Street Address City State / Province / Region ZIP / Postal Code Phone Visa MasterCard Discover Card holder Name Acct# CVC: Invoice Changes: I authorize that I am an authorized user of this credit card and will not dispute payment with my credit card company as long as the transaction corresponds to the terms indicated on this form. I also received copy of my invoice and signed credit card authorization form.SignatureDate MM slash DD slash YYYY
