Authorization for Credit Card Use
ALL INFORMATION IS CONFIDENTIAL. CHALLENGE COINS ARE $10 each.
Front of Coin
Back of Coin
Name as shown on card:
Your answer
Billing Address (Include Zip code) :
Your answer
Credit Card Type:
Credit Card Number:
Your answer
Card Expiration Date (MM/YYYY):
Your answer
Card Identification Number: (last 3 digits on the back of card)
Your answer
How many coins would you like?
Amount to Charge:
I authorize CASRO to charge the amount listed above to the credit card provided herein. I agree to pay for this purchase in accordance with the issuing bank cardholder agreement.
Signature:
Your answer
Date:
MM
/
DD
/
YYYY
Submit
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