CREDIT CARD “ON FILE” AUTHORIZATION FORM IOGLB is authorized to maintain credit card payment information in our confidential files. This form is being provided for you to supply IOGLB this information for the upcoming license year. Your signature authorizes us to review this information and deduct fees from the credit card below, when you sign the applicable application.
_______________________________________ Business Name
_______________ License #
_______________________________________ Outfitter/Designated Agent Signature
_______________ Date Signed
_______________________________________ Printed Name
_______________ License #
Outfitter applications, Designated Agent applications, and Guide application forms include a box that you must sign to authorize use of this credit card for the license fee(s), verbal authorization will not be accepted at any time. *******We only accept Mastercard or Visa at this time*******
Cardholder Name (as imprinted on credit card)
Cardholder Signature Card Number # Expiration Date If anyone other than the cardholder is authorized to use this credit card, please have him or her print and sign his or her name:
_______________________________________ Signature
_______________ Date Signed
_______________________________________ Printed Name
Cardholder Authorizing signature