PAYMENT AUTHORIZATION FORM

She Wiggin' LLC Payment Authorization Form

SIGN AND COMPLETE THIS FORM TO AUTHORIZE SHE WIGGIN' LLC TO MAKE A ONE TIME CHARGE TO YOUR DEBIT/CREDIT CARD BELOW. BY SIGNING THIS FORM, YOU GIVE US PERMISSION TO DEBIT YOUR ACCOUNT FOR THE AMOUNT INDICATED ON OR AFTER THE INDICATED DATE. THIS IS PERMISSION FOR A SINGLE TRANSACTION ONLY AND DOES NOT PROVIDE AUTHORIZATION FOR ANY ADDITIONAL UNRELATED DEBITS OR CREDITS TO YOUR ACCOUNT. THIS FORM MUST BE COMPLETED AFTER PURCHASING UNIT(S).
Name

First Name Last Name
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I, First Name Last Name AUTHORIZE THIS PAYMENT IN THE AMOUNT OF
ACCUATE AMOUNT TO SHE WIGGIN' LLC FOR THE PURCHASE OF THIS UNIT(S).
UPLOAD GOVERNMENT ISSUED ID AND CREDIT CARD BEING USED FOR THIS PURCHASE. SHOW ONLY NAME AND LAST FOUR DIGITS OF CREDIT CARD NMBER. NAME ON ID AND CREDIT CARD MUST MATCH. PLEASE, NO SCREENSHOTS.

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I CERTIFY I AM AN AUTHROIZED USER OF THIS CREDIT/DEBIT CARD AND THAT I WILL NOT DISPUTE THE PAYMENT WITH MY DEBIT/CREDIT CARD COMPANY; SO LONG AS THE TRANSACTION CORRESPONDS TO THE TERMS INDICATED IN THIS FORM.

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She Wiggin' LLC Payment Authorization Form