1. Automatic Credit Card Billing Authorization Form
Credit card information will be kept on file. If payment is not received by invoice due date, the
credit card on file will be charged the first business day after the due date. All requested
information is required. Upon approval, we will automatically bill your credit card for the
amount indicated and your total charges will appear on your monthly credit card statement. You
may cancel this automatic billing authorization at any time by contacting us.
Credit card and billing information is considered confidential information and will ever be made
public or used for any purpose other than billing, without express written authorization.
Client Information
Client name:
Phone:
Email:
Payment Information (To be completed by merchant)
I authorize 7 Veils Media, Inc to automatically bill the card listed below as specified:
Amount:
Frequency: Monthly
Start billing on:
End billing when Service Agreement expires as stated in Service Agreement or Client provides
written cancellation of service agreement. Cancellation subject to Terms of Service.
Credit Card Information (To be completed by client)
Credit card type: Visa
MasterCard Amex
Credit card number:
Expires: /
CVV:
Cardholder's name:
(as shown on credit card)
Cardholder's Zip code (required):
(from credit card billing address)
Client's signature:
Date: