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Credit Card Authorization Form Dear Sir/Madam, This form has been created in order to allow you to have third party expenses charged to your credit card. Please provide all the information requested

Credit cards issued to name of person(s): Full name: Address: Telephone number (cell phone or home telephone): Name and address of business: City: State: Zip Code: Telephone number (regular or mob): Fax number: Signature or other written authorization : Please note: If you authorize a debit card, the signature must be handwritten. We need all information contained in the following fields in order to process your authorization. (Please enter all information on the form) Card Type (Visa, MasterCard, American Express, etc.) Business Name City State Zip Code The following additional information on one or more items of your statement can be filed with our office for the purpose of this authorization form.(Please enter all information on the form) Please send the following to our Financial Services Division. 1) The authorization fee 200 or 300, whichever is less (If requesting a credit card authorization for use on more than one expense, you must pay the authorization fee to each expense.) 2) The authorization notice form (if you are requesting a credit card authorization for use on more than one expense, fill out this form only for expenses related to one expense. If requesting a credit card authorization for different items of cost, please fill out the appropriate form for each item of cost.) Contact Information If you have any questions about this form, you may: Call our office at, ext. 1204 Email or nixlafinance.sale spa.gov Fax the completed form to the address listed on page 1 or to Nicole Quinn at: Nixlafinance Office of Financial Management 1617 North 9th Street Suite 2 Philadelphia, PA 19148 Or you may fax to our Fax:, ext.

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