Ridgewood, NJ 07450, USA
Tel: (201) 445-7088   Fax: (201) 445-5618
Email: service@visarite.net    Web: www.visarite.com

Credit Card Charge Authorization Form


I am a client of VisaRite Service Corp. I hereby authorize VisaRite to charge payment for following service to my credit card:
   Visa Service      Passport Service      Other Services

Service Request Confirmation #:
  Click here to get Service Request Confirmation Number
Card Number:      
Expiration date: /
Card Holder Name:
Card CVC (What's this?)  
  3 digits on the signature panel on the back of the card Visa,Master,Discover
Amount Authorized: + 3% credit card surcharge.
Billing Address:
City: State: Zip:
I understand the government fee, VisaRite service fee and return shipping is non-refundable.
Signature:   <<< Sign Here
By sign this form, you indicate you have read and agree with the terms & conditions set forth by VisaRite.


VisaRite - Visa & Passports Experts