Credit Card Verification Form & Agreement

In order to verify your credit card transaction, please complete and submit the following:

  1. Please provide the required information and print the form.
  2. Ensure that the agreement is signed and date.
  3. Take a photo of the signed form using your smart phone, along with copies of the front and back of your card(s).
  4. Provide a photo of a valid government issued ID.
  5. Submit the images of the signed form, credit card(s) and photo ID in JPEG or PDF format to

Government Issued ID

(e.g. Drivers License)

Front and back of your credit card



To ensure we process your documents without delays, we kindly ask that the name, address, card details and signature on the form are clear and legible.

Client Information

  • Month/Year

IMPORTANT: Please read the following carefully before signing and dating.

By submitting this signed and dated form, along with the additional information requested, I am authorizing and fully acknowledging that:

  • I acknowledge that this account was registered using my personal information and all transactions were initiated and authorized personally, using the above credit card.
  • I agree that all transactions made in my account will be paid in full.
  • I agree that any and all uncollected purchases or delinquent accounts are subject to 3rd party credit reporting and collections.
  • I am over 18 years of age.
  • I have read and accepted the terms described in the Transaction Processing Agreement.




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