One Time Debit or Credit Card Payment Authorization

By submitting this form, you give GR Consumers Credit Union permission to debit your debit or credit card for the amount listed below, plus a $10 convenience fee. This permission is for a single transaction only and does not provide authorization for additional debits from your debit or credit card.

Dollar Amount ($) *

Member Account Number *

Loan Suffix *

Card Information

Name on Card *

Billing Address *

City *

ZIP Code *

Email Address *

Phone Number *

One Time Debit or Credit Card Payment Authorization

Continued

Type of Card:

Visa

AMEX

Card Number *

Expiration Month/Year *

CVV (digit number on back of Visa/MC, 4 digits on front of AMEX)

Authorization to Perform This Payment

I authorize GR Consumers Credit Union to charge the debit or credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the loan account listed above, for the amount indicated above, plus a $10 convenience fee, and is valid for one time use only.

I certify that I am an authorized user of the above debit or credit card and that I will not dispute the above transaction, so long as the transaction corresponds to the terms indicated in this form.

I understand that if the transaction is declined by my debit or credit card company, the payment will not be posted to my loan account.

By checking the box, I agree and consent to the terms listed above.

Thank You