One Time Credit Card Authorization - CEM Mare One time authorization for credit card payment/charge for CEM services provided by Rogue Equine CEM. Cardholder Name ( as it appears on card)* First Middle Last Card Type*VisaMastercardAmerican ExpressDiscoverLast 4 digits* Expiration Date* MM slash DD slash YYYY Billing Address ZIP Code* ZIP Code Name of Person Signing* First Middle Last Consent to record and retain authorization.* I agreeI hereby authorize Rogue Equine CEM to process the above Credit Card as "Signature on File" for ONE TIME CEM services in the amount of $2652.25 ($2575.00 plus card transaction fee of $77.25). I understand that this information will NOT be saved for future transactions.Signature of Person Signing*User finger for tablets or phone, mouse if using a PC/Mac. Date of Signing* MM slash DD slash YYYY Your card is not processed until completion of the next step. Immediately after submission of your form you will see a confirmation page with a link to our secure card processing site. Please enter the amount of $2652.25 and your card details. Thank you! CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
