Credit Card Authorization Form

This information is confidential. This form will only be kept by Hera Hub Accounting Department.

Name*

First Last

Name on the card if different from above

First Last

Email*

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Card Number*

Expiration Date*

Enter as MM/YY

4 Digit CID (American Express)/ 3 Digit CV Code*

What is this payment for?*

Total Charges Agreed To*

Confirm with Hera Hub staff before if unsure

By checking the box below I consent to pay the above amount*

I agree