Credit Card Authorization Form

Credit Card Authorization Form

All information provided here is securely encrypted and HIPAA-compliant
Card Type *

Visa Mastercard Discover Amex
Cardholder Name as shown on the card *

First Name Last Name
Card Number *
Expiration date (MM/YYYY) *
CVC Code (3 or 4 digit security code on the back of card) *
Cardholder Zip Code (from credit card billing address) *
I, First Name* Last Name*, authorize TTHI of New England Inc. dba Inspire Counseling and Support Center, Inc 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.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty: