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Credit Card Payment Authorization Form
Nameyour full name
This form has been created to allow you to have third party expenses charged to your credit card. We ask that you sign and complete this form to authorize Beauté à Porter 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 hereby authorize Beauté à Porterto charge my credit card for:
City, StateZip code
Account Type:pick one!
NameCardholder Name
SIGNATUREyour full name
DateToday's date
I authorize the above named business to charge the credit card indicated in this authorization form according to theterms outlined above. This payment authorization is for the goods/services described above, for the amountindicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit cardand that I will not dispute the payment with my credit card company; so long as the transaction corresponds to theterms indicated in this form.