Credit Card Authorization FormPlease complete the form for data capture and credit card authorization Your information has been successfully submitted. You will soon receive a copy of the 'Credit Card Authorization' in your email. 11https://pba-panama.com/wp-content/plugins/nex-formsfalsemessagehttps://pba-panama.com/wp-admin/admin-ajax.phphttps://pba-panama.com/paymentsyes1fadeInfadeOut *Card NumberPlease enter the 16 digits of the cardMask Card NumberPlease enter the 16 digits of the card*Cardholder's First and Last NameAs it appears on the card*Expiration Datemonth / year*CVV Security Code3 or 4 digits on the back of the card*Type¿Amex, Visa o MasterCard?-Seleccione-AmexVisaMasterCardOther*Email AddressWhere a copy of this form will be sent.*Phone NumberFor communication via WhatsApp and SMSCompany NamePlease indicate the name of the company you represent.ID / RUCTax Identification Number or ID Number*Short AddressBilling Card Short Address*Terms and Conditions.I authorize PBA Holding Group, Inc. to charge my credit card mentioned above for the agreed services.*SignaturePlease draw your signature in the box.SUBMIT
