google adwords form

1. AUTHORIZATION FORM
AUTHORIZATION FORM
Yes! I would like to set up an automatic debit for my Google AdWords bill to my credit card account.
The entire amount of my bill relating to advertising on Google AdWords and/or related expenses on
my Google AdWords Customer ID should be debited to my
VISA MasterCard (tick as appropriate)
Credit Card Number
M M Y Y Y Y
Expiry Date
Issued By
D D M M Y Y Y Y
Date of Birth
I understand and undertake that
• Expenses related to my Google AdWords account will be charged to my above credit card (monthly,
earlier, or if and when accrued)
• The record of charges in respect to the above services received or availed by me and submitted by
Google India Pvt. Ltd. to my credit card account will neither bear my signature nor imprint of my card
• A copy of the bill showing expenses will be sent to me as usual
• These instructions are valid on an ongoing basis till I issue instructions to the contrary in writing to the
bank with a copy to Google India Pvt. Ltd.
I agree to advise Google India Pvt. Ltd. if the above credit card account is cancelled, substituted or not renewed.
I therefore undertake to unconditionally honor and pay without demur and contestation the said charges when I
am billed for the same by the above mentioned bank
Signature (as appearing on the credit card) Date
Name as appearing on the credit card Place
(Enclose a photocopy of both sides of the credit card)
Billing address associated to your credit card Contact Phone Number