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Credit Card / ACH Payment Authorization
Check One (1) and Enter Your Details
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❑ - Recurring Charge - You authorize regularly scheduled charges to your credit card or
bank account. You will be charged the amount indicated below each billing period. A
receipt for each payment will be provided to you and the charge will appear on your
credit card or bank statement. You agree that no prior-notification will be provided unless
the date or amount changes, in which case you will receive notice from us at least 10
days prior to the payment being collected.
I _______________________ authorize _________________________ to charge my
(Full Name) (Merchant’s Name)
Credit Card or Bank Account below for $________________ on the ______________
(Amount $) (day) of
each ________________.
(week, month, etc.)
This payment is for ________________________________.
(Description of Goods/Services)
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❑ - One (1) Time Charge – Sign and complete this form to authorize the merchant below
to make a one-time charge to your credit card or bank account listed below.
By signing this form, you give us permission to debit your account for the amount
indicated on or after the indicated date. This is permission for a single transaction only,
and does not provide authorization for any additional unrelated debits or credits to your
account.
I _______________________ authorize _________________________ to charge my
(Full Name) (Merchant’s Name)
credit card or bank account indicated below for $_______________ on ____________.
(Amount $) (Date)
This payment is for ________________________________.
(Description of Goods/Services)
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Billing Information
Billing Address ___________________________ Phone # ______________________
City, State, Zip ___________________________ Email ________________________
Bank (ACH) Credit Card
❑ Checking ❑ Savings
Name on Acct
_______________
Bank Name
_______________
Account Number _______________
Routing Number _______________
❑
Visa ❑ MasterCard
❑
Amex ❑ Discover
Cardholder Name _______________
Account Number _______________
Exp. Date _______ / _______
CVV _______
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the
merchant in writing of any changes in my account information or termination of this authorization at least
15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I
understand that the payments may be executed on the next business day. For ACH debits to my
checking/savings account, I understand that because these are electronic transactions, these funds may
be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an
ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that the merchant may at its
discretion attempt to process the charge again within 30 days, and agree to an additional $_____ charge
for each attempt returned NSF which will be initiated as a separate transaction from the authorized
recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with
the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will
not dispute these scheduled transactions with my bank or credit card company; so long as the transactions
correspond to the terms indicated in this authorization form.
BANK ACCOUNT / CARHOLDER’S SIGNATURE ___________________________
DATE _____________________