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  • UWorld Payment Authorization Form

    Uploaded by

    Paul Entrata
    103 views1 page
    This document is a payment authorization form from USMLEWorld, LLC containing transaction details for a $109 purchase by user ID 1083226 using a credit card ending in 4374. The cardholder must sign to authorize either their own purchase and receipt of goods, or to allow an authorized user to make the purchase using the cardholder's card and agree to the company's terms of service. Instructions are given to email or fax identification documentation to complete the authorization process.

    Original Description:

    uworld

    Original Title

    1083226 UWorld Payment Authorization Form (1)

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    This document is a payment authorization form from USMLEWorld, LLC containing transaction details for a $109 purchase by user ID 1083226 using a credit card ending in 4374. The cardholder must sign to authorize either their own purchase and receipt of goods, or to allow an authorized user to make the purchase using the cardholder's card and agree to the company's terms of service. Instructions are given to email or fax identification documentation to complete the authorization process.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    103 views1 page

    UWorld Payment Authorization Form

    Uploaded by

    Paul Entrata
    This document is a payment authorization form from USMLEWorld, LLC containing transaction details for a $109 purchase by user ID 1083226 using a credit card ending in 4374. The cardholder must sign to authorize either their own purchase and receipt of goods, or to allow an authorized user to make the purchase using the cardholder's card and agree to the company's terms of service. Instructions are given to email or fax identification documentation to complete the authorization process.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 1

    USMLEWorld, LLC dba UWorld

    545 E. John Carpenter Freeway, Suite 1600


    Irving, TX 75062

    Phone: (972) 887-3293


    Fax: (972) 887-3296

    Payment/Charge Authorization Form

    Card Holder Information Authorized User Information

    Name Name

    Address Address

    City City

    State State

    Zip Zip

    Internal Use Only (Transaction Information)

    Card # Last 4 Digits 4374 UserId 1083226

    Amount $109.00 USD Txn ID 1fmsz0pw

    Date 10/4/2017

    I am the card holder and participated in said transaction and received the
    merchandise. I agree to the UWorlds Terms of Service
    (www.uworld.com/terms_conditions.aspx)
    OR
    I am the card holder and have given permission to the listed account holder to
    use this card. The authorized card user has received the merchandise and is
    aware of UWorlds Terms of Service (www.uworld.com/terms_conditions.aspx)

    Card holder Signature: _______________________________ Date:__________________

    Instructions
    Please have the card holder complete the form, check applicable statement and send
    the below via email to support@uworld.com or faxed to 972-887-3296 for review:
    Send signed copy of this document,
    Image of the card used displaying the last 4-digits & Name (all other numbers
    may be obscured),
    Valid photo ID for the cardholder

    UWorld, 545 E. John Carpenter Freeway, Suite 1600, Irving, TX 75062


    Tel: (972) 8873293 Fax: (972) 8873296 www.uworld.com

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