LIALOHA — Credit Card Authorization

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Credit Card Authorization Form

By submitting this form you authorize Lialoha, Inc. to charge your account

📋 Please complete all fields. This authorization allows Lialoha, Inc. to debit your account on or after the indicated date. Purchases are non-refundable — exchanges or store credit available within 5 working days.

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Card Holder

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Exp. Date

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Company Name *

Required.

Name on Card *

Required.

Card Type *

Required.

Credit Card Number *

Please enter a valid card number.

Exp. Date *

Required.

CVV *

Required.

Billing Address with ZIP *

Required.

Date *

Required.

Printed Name *

Required.

I hereby authorize Lialoha, Inc. to charge my above listed credit card. I understand that this purchase is non-refundable. If not satisfied, can be exchanged or credit issued within 5 working days of purchase. I certify that I am an authorized user of this credit card and that I will not dispute this payment with my credit card company.

You must agree to proceed.

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Authorization Submitted!

Your Credit Card Authorization has been received by LIALOHA.
We will process your account and follow up shortly.

Reference Number