Credit Card Payment Authorization

Sign and complete this form to authorize SCALE Healthcare to make charges to your Credit Card listed below.

By signing this form, you give us permission to debit your  account for the amount indicated on or after the indicated date. This is permission for transactions related to your SCALE Education account and does not provide authorization for any additional unrelated debits or credits to your account.

    I authorize SCALE Healthcare to charge my Credit Card indicated below.

    Billing Details

    Billing Address

    City, State, Zip


    Phone Number

    Credit Card Information

    Cardholder’s Name

    Credit Card Number

    Expiration Date (mm/yy)/

    Security Code (CVV)

    Individuals Signature

    [signature* signature-809 color:#000000 backcolor:#dddddd width:300 height:200]


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