Authorization - Mirage Carnival

P.O. Box 383, Murray’s Village, St. Vincent W.I.
www.miragecarnival.com| Email: registration@miragecarnival.com
Telephone: 784 494 2424 Fax: 784 456 2645

Mirage Credit Card Authorization Form

Sign and complete this form to authorize Mirage Productions to make a one time debit to your credit card listed 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. Your information will be discarded once payment is received.

Please complete the information below:

First Name

Last Name

Contact Number

authorize Mirage Productions to charge my credit card account indicated below for

Enter amount in EC

on or after

This payment is for

Order #

In Section

Your Billing Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Card Type

Payment Type

Cardholder Full Name

Card Number

Expiration Date

CVV2

Signature

Sign Here

Today's Date

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.