Home Stop Smoking Lose Weight FAQ About Us
Laser Solutions of S. Florida
1154 S. Powerline Rd
Pompano Beach, Fl 33069
954-972-2888
CREDIT CARD AUTHORIZATION FORM
DATE:________________
This receipt is for purposes of recording an authorized charge or payment on your (or
with) VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER, CHECK OR CASH
Payment is for the following:_____________________________________
NAME:___________________________________________( as it appears on card)
CREDIT CARD HOLDER’S ADDRESS OR WHERE THE CREDIT CARD BILL IS RECEIVED:
Address:_____________________________________________________________________
City:______________________________________________State________Zip___________
Signature:_____________________________________
Amt. to charge
Card number:______________________________________Exp. Date___________________
METHOD OF PAYMENT:______________________________
Credit card authorization code___________________________(office use only)