Credit Card Authorization Form

Name *

First

Last

Please DO NOT fill out this form if you are paying by ZELLE, VENMO, CASHAPP, etc. Your card WILL be charged by submitting this form.

Email *

Please DO NOT fill out this form if you are paying by ZELLE, VENMO, CASHAPP, etc. Your card WILL be charged by submitting this form.

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Credit Card Number * *

Enter your 16 digit credit card number here

Expiration Date *

Please enter your credit card expiration date in MMYY format. Do not include a front slash. (/)

CVV *

Please enter the 3 or 4 digit CVV/security code located on the back of your card

Order Number *

Order Total *

Please include the full dollar amount of your order here.

Checkboxes *

I authorize accelerate-labs to process a transaction for the above dollar amount to the card associated with the information I provided on this form .

Signature (Type Your Name)

Please DO NOT fill out this form if you are paying by ZELLE, VENMO, CASHAPP, etc. Your card WILL be charged by submitting this form.