Credit Card Authorization Form

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

Card Type

Cardholder Name (As shown on card)

First Name

Last Name

Card Number

Expiration Date (mm/yy)

Cardholder ZIP Code (from credit card billing address)

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I authorize Lead Logger 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.

Yes

Your Name

Your Email