Credit Card Authorization Form

By signing this form, you give us permission to debit your account for the amount indicated on or after the indicated date of receiving this authorization. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account. Your account details are secured with an end-to-end encryption

I, (Card holder’s name as required below), authorize PC-Inc,USA to charge my credit/debit card with the exact amount as indicated below. By clicking the “Sign & Authorize” button below, I therefore agree that my card will be charged on today’s date or within 2 days for the amount indicated below.

Secure Online form with COMODO RSA SSL end-to-end encryption

16 digit card number. Ex. 4509-0000-0000-0000
Enter exact card billing address
Separate with a comma. Ex. City, State, Country, Zip Code
3 or 4 digit code at the back of your card
Enter the phone number associated with the card above. International clients must input their country's dialing code
Input the amount on your order. Amount must be in USD $$$
Enter the email address associated with your order

Select your currency
USD United States (US) dollar
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