Credit Card Payment Authorization Form

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.

Organization Name:

Name of Person Authorizing the Charge:

Billing Address:




Country :

E-mail :

List Invoices to be Paid:

List Invoices to be Paid:

Total Charge Amount:

Must Charge Each Invoices Separately:
 Yes No

Receipt Needed:
 yes No

Credit Card Details

 Visa MasterCard AMEX Discover

Cardholder Name:

Account Number:

Expiration Date:

CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX):

 I authorize Hue Marcom Services Pvt. Ltd. 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.