US POLE SPORT FEDERATION
Automatic Credit Card Billing Authorization
Customer Information
Customer Name:
Division:
Phone:
-
-
Payment Information (To be completed by merchant)
The athlete authorizes the USPSF to automatically bill the card listed below in the case of a breach of contract as
specified in the athlete participation contract.
Amount: $500
Bill on:
Or when contract
is breached.
3
/ 12
/16
Credit Card Information (To be completed by customer)
USPSF accepts the following credit cards: Visa, MasterCard, American Express, Discover
Credit card type:
Credit card number: (Just list last four digits, we will call you for the
remaining numbers)
Expires:
/
Cardholder's name:
Cardholder's Zip code (required):
(as shown on credit card)
(from credit card billing address)
Customer's signature:
Date: