One Time Credit Card Payment Authorization Form

Complete this form to authorize Blackwell Photography to make a one time debit to your credit card listed below.  

By clicking "I Agree" below this form you give us permission to debit your account for the amount indicated on or after the indicated date.  This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

Please complete the information below:

Name *
Name
Same Name as on Card
Phone
Phone
Date of Photography Services
Date of Photography Services
$
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form. Blackwell Photography uses Square to process Credit Cards. A 5% processing fee is added to all credit card transactions. A receipt will be sent to the e-mail listed above from Square after the transaction is completed. *