One Time Card Transaction CEM Stallion - Rogue Equine & Companion Animal Clinic

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*
Last 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 agree
I hereby authorize Rogue Equine CEM to process the above Credit Card as "Signature on File" for ONE TIME CEM services in the amount of $6849.50 ($6650.00 plus card transaction fee of $199.50). I understand that this information will NOT be saved for future transactions. Thank you!
Signature of Person Signing*
User finger for tablets or phone, mouse if using a PC/Mac.
This field is hidden when viewing the form
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 $6849.50 and your card details. Thank you!
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