1-Time Credit Card Payment Authorization Form

1 Star2 Stars3 Stars4 Stars5 Stars (No Ratings Yet)

The 1-time credit card authorization form allows a card holder to permit a third party to perform a one (1) time debit to their credit card listed within the document. This efficient document will list the account holder’s name, the name of the individual to whom their given permission, the amount to be withdrawn as well as the credit card information which will allow the transaction to take place without the card or the card holder present. The below form can be used for Visa, MasterCard, American Express, and Discover. It should be noted that once the transaction has taken place, the authorization form will become null and void.

How to Write

Step 1 – Begin by downloading the 1-time credit card authorization form in Adobe PDF.


Step 2 – Read over the first two paragraphs to gain a full understanding of purpose of the form and what you’re consenting to. Enter the name of the individual who is being given the authority to make a one-time debit to your credit card.

Step 3 – The following information must be supplied next:

  • Your Name
  • Name of authorized individual
  • Amount of money being charged to the credit card
  • Date of transaction
  • Description of product or purpose of the payment

Step 4 – Next, enter the billing address, your phone number, and your email address.

Step 5 – The account information has to be submitted next. Provide the following:

  • Account Type (Visa, MasterCard, American Express, or Discover)
  • Cardholder Name
  • Card Number
  • Expiration Date
  • CVV2 Number

Once the account information has been submitted, provide the date, the name of the authorized individual, and print off the document. Provide your signature to complete the form.