Credit Card Authorization Form

Krav Maga Nation Credit Card Authorization Form

Student name*
First Last
Email*
Cardholder name*
First Last
Card provider*
Card number*
Expiry date - month*
Expiry date - year*
CSV number*
Electronic signature*
Type in your full name
Membership type*
Today's date*
Please note that by completing this form you are authorizing Krav Maga Nation to process your monthly membership fee on the above noted credit card. Your information will be stored in a secure system and will be obfuscated (e.g. 4551XXXXXXXX235) so as to protect the information in the system. Payments will be processed on your monthly payment date automatically until notice is given (at least 10 days prior to payment date) to halt or cancel payments. A charge of $25.00 will apply for any dishonoured payments.
*
- I agree with the authorization terms and conditions
Additional notes/comments