Credit Card Verification Agreement

Simply complete the following agreement form to verify your credit card.

  1. Fill in all of the required information and print the form.
  2. Date and sign the completed form.
  3. Take a photo of the front and back of your credit card(s) and the signed form using your smartphone.

  4. As well, take a photo of a valid government issued photo ID.

  5. Send us the photos of the signed completed agreement, credit card(s) and a copy of your government issued photo ID in JPEG or PDF format to

Government Issued ID

(e.g. Drivers License)

Front and back of your credit card



To avoid delays in the verification process ensure that your name, address, credit card number and signatures on the documents you’re submitting are clearly legible.

Client Information

  • Month/Year

IMPORTANT: Carefully read the following before signing and dating the agreement.

By submitting the signed and dated agreement and the additional required documentation, I am authorizing and fully acknowledging the following:

  • I acknowledge this account was registered using my personal information and all transactions were initiated and authorized personally, using the above credit card.
  • I agree all transactions made in my account will be paid in full.
  • I agree any and all uncollected purchases or delinquent accounts are subject to 3rd party credit reporting and collections.
  • I am over 18 years of age or older.
  • I have read and accepted the terms described in the Transaction Processing Agreement.




​Email To

​Fax To

US Residents: xxx-xxxx-xxxx