One Time Credit Card Payment Authorization Form

Complete this form to authorize Mamuya Safaris to make a one time debit to your credit card listed below. By submitting 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.

    Your Name (required)

    Your Email (required)

    Your Card Number (required)

    Expiration Date (required)

    CV CODE (required)

    Billing Amount

    Agreement: I authorize Mamuya Safaris to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the Safari/Travel services described in my Invoice, for the amount indicated in my Invoice 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.