Payment Authorization Form


Please complete all the fields in the form below. You may cancel the authorization at any time by contacting. The authorization will remain in effect until cancelled.

Card Type

 

Note: 3% processing fee will be applied on all transaction using your credit card.

I,   authorize VA Healthcare Transportation LLC to charge my credit card above for agreed upon purchases. I understand that my information will saved to file for future transaction on my account.

 

Leave this empty:

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Signature Certificate
Document name: Payment Authorization Form
lock iconUnique Document ID: 7d392cbb88d92914543cc57d607f86e3925c2ec0
Timestamp Audit
September 3, 2021 6:00 am EDTPayment Authorization Form Uploaded by Mohamed Awl - vahealthcaretransportation@gmail.com IP 122.129.80.21