Credit Card Authorization Form

Authorization for automatic credit card transactions

Name
First Last
Billing Address*
Street Address City State ZIP Code
Card Number*
PLEASE INCLUDE DASHES
Exp. Date
CVV*
Debit or Credit
- Debit
- Credit
Card Type
Signature*
Date Submitted
Date Format: MM slash DD slash YYYY
Email*
Consent*
I agree to the terms and conditions.
By signing below I hereby authorize the Ellsworth Farmers Exchange to automatically charge my credit card for my monthly purchases. In exchange for this authority, I understand that I will be eligible for any prompt payment discounts in effect at the time.

Further, I understand that it is my responsibility to provide the Ellsworth Farmers Exchange with a valid credit card number, CV2 code* and expiration date and that I may forfeit any available discount if my credit card on record is declined.