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Recurring Payment Authorization Form
Customer Information (to be completed by merchant)
Account number
Email address
Customer/company
Product/service description
Contact name
Payment Information (to be completed by merchant)
Credit Card Information (to be completed by customer)
I authorize to automatically bill the card listed below as specified:
QuarterlyOnce Weekly Twice/month Monthly
MasterCard VISA AMEXDiscover
Frequency
(check one)
(as shown on card)
Customer’s signature Date
(from credit card billing address)
Card type
Cardholder name
Card number Expires ___________/____________
Cardholder ZIP Code
merchantcustomer
If you would like to enjoy the convenience of automatic recurring billing, simply complete the Credit Card Information section below and sign the form.
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.
Other
( ) - Ext:Phone
Recurring amount
Notify me via email when my credit card is charged. (Make sure email address above is correct.)
Start on ______________/________ /__________________
Month Day Year
End on: ______________/________ /__________________
Month Day Year
No end date
(check one)
Daily

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Authorization form

  • 1. Recurring Payment Authorization Form Customer Information (to be completed by merchant) Account number Email address Customer/company Product/service description Contact name Payment Information (to be completed by merchant) Credit Card Information (to be completed by customer) I authorize to automatically bill the card listed below as specified: QuarterlyOnce Weekly Twice/month Monthly MasterCard VISA AMEXDiscover Frequency (check one) (as shown on card) Customer’s signature Date (from credit card billing address) Card type Cardholder name Card number Expires ___________/____________ Cardholder ZIP Code merchantcustomer If you would like to enjoy the convenience of automatic recurring billing, simply complete the Credit Card Information section below and sign the form. 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. Other ( ) - Ext:Phone Recurring amount Notify me via email when my credit card is charged. (Make sure email address above is correct.) Start on ______________/________ /__________________ Month Day Year End on: ______________/________ /__________________ Month Day Year No end date (check one) Daily