CREDIT CARD AUTHORIZATION

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

Cardholders Name (as it appears on the card):

Address

Billing Address

City

State

Country

Postal code

Card Type:

MasterCard

VISA

Discover

AMEX

Other

Card Number

CVC

Expiration Date

Phone

I authorize Group To Go, Inc. to charge my credit card for the authorized amount. I understand that my information will be saved to file for future transactions on my account.

Today’s Date: