CHICAGO KITCHEN OUTLET
300 W NORTH AVE.
VILLA PARK, IL 60618
One Time Credit Card Payment Authorization Form
Sign and complete this form to authorize Chicago Kitchen Outlet to make a one-time debit to your credit card listed below. By signing this form, you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account.
Yes, I authorize Chicago Kitchen Outlet to charge my credit card account indicated above the amount and date.
I authorize the above-named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.