Credit Card Authorization Form

Customer Business Name: *

Email address *

Layout

Lotus Sales/Invoice Order Number *

Amount to Charge *

Do you have a credit card on file? *

Leave this card on file for future orders? *

Card Type *

Last Four of card on file *

Name of card holder *

First

Last

Credit Card Number (VISA) *

Credit Card Number (MC) *

Credit Card Number (AMEX) *

CVV *

CVV (Front of card) *

Layout

Billing Address *

Address Line 1

Address Line 2

City

State

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 *

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