Credit Card Authorization Form

Office Information:

Florida Youth Soccer Association
2828 Lake Myrtle Park Rd
Auburndale, Florida 33823
Phone: (863) 268-8220
Fax: (863) 268-8221

Date: *

Name: *

Visa/MasterCard/Discover/AmEx Number: *

Expiration Date of Credit Card: *

3 Digit Security Code from the back of Card: *

Debit Amount: *

Name as it appears on the Card: *

Phone Number: *

Address: *

City: *

State: *

Zip Code: *

Purpose of Charge: (ODP, Registration, etc.) *

I authorize the Florida Youth Soccer Association, Inc. to charge my credit card.