Payments - AOR

Client/Company Name*

Credit Card Type*

Credit Card Number*

Name On Card*

Expiration*

CVC*

Billing Address Line 1*

Billing Address Line 2

Billing City*

Billing State*

Billing Zip*

Please choose your 'forget by' preference*

AOR will automatically delete this information on the following date:

AOR is authorized to use this card for...

AOR is authorized to use this card for recurring charges on these platforms...

AOR is authorized to use this card for recurring charges on these additional platforms...

One Time Charge: AOR is authorized to incur a maximum charge of...($)

One Time Charge: AOR is authorized to charge this card for the following service(s)

Specify Invoice Numbers (If Applicable)

We are fully compliant with PCI DSS v3.2 for the payment-related data we collect from you but we have no plans to obtain a PCI Report-on-Compliance due to the limited use of credit card payments.

AOR Secure Credit Card Intake

Client/Company Name*

Credit Card Type*

Credit Card Number*

Name On Card*

Expiration*

CVC*

Billing Address Line 1*

Billing Address Line 2

Billing City*

Billing State*

Billing Zip*

Please choose your 'forget by' preference*

AOR will automatically delete this information on the following date:

AOR is authorized to use this card for...

AOR is authorized to use this card for recurring charges on these platforms...

AOR is authorized to use this card for recurring charges on these additional platforms...

One Time Charge: AOR is authorized to incur a maximum charge of...($)

One Time Charge: AOR is authorized to charge this card for the following service(s)

Specify Invoice Numbers (If Applicable)