Credit Card Authorization | DATE: ____/____/____ |
I, ______________________________________________________________, hereby authorize Captain Cook's Cruise Center, on behalf of HealingYou.org, to charge my [ ]MasterCard [ ]Visa Number: ________-________-________-_______ expiring on ____/____ in the amount of $_______.___, for the following product(s): ________________________________________________________________ __________ Product Name Quantity ________________________________________________________________ __________ Product Name Quantity ________________________________________________________________ __________ Product Name Quantity (For additional products, attach additional sheets) under order number _________________________. I understand the terms and conditions of this authorization and agree to indemnify and hold harmless HealingYou.org, Captain Cook's Cruise Center, and all natural persons associated with HealingYou.org, and Captain Cook's Cruise Center, hereinafter referred to collectively as "HYO", from and against all liabilities, losses, charges, costs, and expenses incurred by "HYO", as a result of any credit card charge-back received in connection with this authorization. A charge-back is defined as the reversal of any charge made to a person's credit card account where such and any reversal thereof was made in connection with the aforementioned purchase. This indemnification is only for charge-backs received by Captain Cook's within one year from the date of this authorization or one year beyond the date of delivery of the purchased product, which ever is longer. I authorize Captain Cook's Cruise Center to collect charge-back fees and related costs resulting from any act or action taken by me or on my behalf up to a maximum of $50.00 but in no case less than $10.00 per charge-back by charging my credit card for these fees and costs. CHECK AND INITIAL FOR CONTINUING PURCHASES: [ ] ___ This form shall be valid for all orders after this order without the need to file a new form for each order. Each order placed after this order shall amend this authorization by adding each such order and amount to this authorization and extending the period of time this authorization remains valid for an additional twelve (12) months following each such order. ________________________________________________________________ ___________ Cardholder's signature Date Be sure to include:
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