Secure Credit Card Authorization Form
Dealership Name:
*
Card Type:
*
Please Select One
American Express
Visa
Discover
Mastercard
Please select one of the following choices.
Credit Card Number:
*
Please insert your credit card number as it appears on the card.
Expiration Date:
*
Please use MM/YYYY format.
Security Code
*
For American Express, this is the 4 digit number located on the front of the credit card. For Visa, Mastercard, and Discover, this is the three digit number located on the back ot the credit card.
Name As it Appears On Card:
*
Prefix
First
*
Last
*
Suffix
Billing Address:
*
This is the address that the credit card statements are sent to.
Street Address
*
Address Line 2
City
*
State / Province / Region
*
Postal / Zip Code
*
Country
*
Authorized Amount:
*
Please enter the dollar amount authorized to be charged by S.M.A. Alliance for services.
Dealership Signature
Please digitally print your name and initial your signature authorizing S.M.A. Alliance to process your credit card for services.
Authorized Signer Name:
*
Prefix
First
*
Last
*
Suffix
Position:
Digital Signature:
*
Please use your initials to digitally sign this credit authorization form.
Email