Credit Card Authorization Form

*This is only a digital authorization form.  Filling this out will not process your card.  KB Everstone customer service will use this to process your payment.  Thank you.

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Customer Business Name: *

Email address *

Lotus Sales/Invoice Order Number *

Amount to Charge *

Do you have a credit card on file? *SelectYesNo

Leave this card on file for future orders? *SelectYesNo

Card Type *

• Visa
• Mastercard
• Amex
• Discover

Last Four of card on file *

Name of card holder *

First

Last

Credit Card Number (VISA) *

Credit Card Number (MC) *

Credit Card Number (AMEX) *

Credit Card Number (Discover) *

CVV *

CVV (Front of card) *

Card Expiration Month *SelectJan (1)Feb(2)Mar(3)April(4)May(5)June(6)July(7)Aug(8)Sept(9)Oct(10)Nov(11)Dec(12)

Card Expiration Year *Select20232024202520262027202820292030203120322033

Billing Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Copy of ID and Credit Card (only required for non-corporate cards)

Click or drag a file to this area to upload.

Authorization *

• I authorize Lotus Business, LLC. to bill my credit card for the above order and amount. No Third Party credit cards accepted. All personal (non-corporate cards) must have copy of state issued ID and credit card attached above.

Authorized Signautre *

Clear Signature

Authorized Signer *

First

Last

Submit