Named Credit Card or EFT Authorization Form

"*" indicates required fields

Member Name*

First Last

Member's Email*

Name as it appears on card*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Credit Card Type*

Last 4 digits of credit card*

Please enter a number from 0000 to 9999.

Authorized Representatives

Appointment 1 (Authorized Representative)

First Last

Appointment 1 Address

Street Address City State / Province / Region ZIP / Postal Code Country

Appointment 2 (Authorized Representative)

First Last

Appointment 2 Address

Street Address City State / Province / Region ZIP / Postal Code Country

The fees associated with this purchase will appear on my active credit card statement or EFT Statement through the identifier “OOIDA”. I agree to pay all fees for services, state and federal fees combined. I am aware that I will receive a copy of the charge slip and that this slip will act as my record of this transaction. Failure to use services does not constitute a basis for refusing to pay any of the associated charges.

****Cardholder is required to provide verbal authorization payment and provide their full credit card number, expiration date, and the authorization code once the signed document is received. ****

By signing this form, you authorize your credit card or EFT to be charged by OOIDA for services purchased from CMCI fees associated with this account.