The Dobson Association, Inc. 2719 S. Reyes ♦ Mesa, AZ 85202 ♦ (480) 831-8314
Credit Card Authorization Form Please complete this authorization to charge your credit card Cardholder Name: ____________________________ Dobson Ranch Acct Number: ______________________ Email Address: __________________________________ Daytime Telephone: __________________________ ONE TIME CHARGE I authorize a one-time charge against my credit card in the following amount $____________________. RECURRING CHARGE I authorize a (choose one) monthly or quarterly recurring charge against my credit card in the amount of $______________, beginning on ________________ , and ending on _________________. Credit card (choose one): MasterCard
Visa
Discover
Credit Card Number: _____________________________________________ Expiration Date: __________________ Billing Address (where credit cards are sent): _______________________________________________ _______________________________________________ _______________________________________________ __________________________________________ Cardholder Signature
Rev. 2/2019
_____________________________ Date