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Credit Card Authorization
info@mtkgym.com
2024-10-22T06:17:55+00:00
Credit Card Authorization
By filling out this form you give authorization and consent to Muay Thai Kickboxing Gym to charge your credit card per the agreement you made verbally, by phone and/or email. To cancel this authorization you must make a request by email with the subject "CREDIT CARD AUTHORIZATION CANCELLATION" to info@mtkgym.com. Authorization cancellations go into effect 8 days after the request. Chargebacks will be disputed with your credit card issuer and, by submitting this form, you agree to be liable to a fee of 15% of the total chargeback amount on top of the original charge.
Name on Card
(Required)
Billing Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Type of Credit Card (Visa, MC or AMEX)
(Required)
Visa
Mastercard
Amex
Credit Card Number
(Required)
Exp. Date
(Required)
3 or 4 Digit SCV (Security Code)
(Required)
Email to send invoice to:
(Required)
Signature
(Required)
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Name
This field is for validation purposes and should be left unchanged.
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