IC Hosting Program Overview Travel Leaders Independent Advisor Program | Page 7

Credit Card Authorization Form
Name: ____________________________________________________________________________________
Billing address: _____________________________________________________________________________
City: __________________________________ State: ____________________ Zip: _____________________
Payment Authorization
Credit card type:
o VISA
o MasterCard
o Discover
o American Express
Card Number: ______________________________________________________________________________
Expiration Date: ________________________ Card Identification Number (CVV): _______________________
I, __________________________________________ authorize Travel Leaders Market Square to process
a charge against my credit card number in the amount of $ 75.00 for the payment to process my initial forms
and background check to be considered for opportunity as an Independent Contractor. I understand that this
fee is non-­‐refundable.
Print Name (as it appears on the credit card): _____________________________________________________
Signature: ___________________________________________ Date: ________________________________
This is NOT a contract. Your contract will be offered following successful
completion of the background check.