Credit Card Billing Authorization Form

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{company_phone}}

Email: {{company_email}}

Website: {{company_website}}

Credit Card Billing Authorization Form

I, {{customer_name}}, authorize {{company_name}} to charge my credit card for payments as outlined below. I understand this authorization will remain in effect until I cancel it in writing.

Customer Information

Customer Name: {{customer_name}}

Billing Address: {{customer_billing_address}}

Phone Number: {{customer_phone}}

Email Address: {{customer_email}}

Credit Card Information

Card Type: {{card_type}} (e.g., Visa, MasterCard, American Express)

Cardholder Name: {{cardholder_name}}

Card Number: {{credit_card_number}}

Expiration Date: {{expiration_date}} (MM/YY)

CVV/CVC: {{cvv_cvc}} (for one-time payments only, should not be stored for recurring)

Authorization Details

Please select the authorization type:

[ ] Recurring Payments: I authorize {{company_name}} to automatically charge my credit card for {{frequency}} payments of {{currency}}{{amount}} starting from {{start_date}}.

[ ] One-Time Payment: I authorize {{company_name}} to charge my credit card a one-time payment of {{currency}}{{amount}} on {{payment_date}} for {{service_description}}.

Terms and Conditions

1. I certify that I am the authorized user of this credit card and that I will not dispute scheduled transactions with my credit card company, provided the transactions correspond to the terms indicated in this authorization form.

2. I understand that if a payment is declined, {{company_name}} may attempt to process the payment again or notify me to update my payment information.

3. I agree to notify {{company_name}} in writing of any changes to my credit card information or if I wish to revoke this authorization.

4. This authorization will remain in effect until cancelled in writing by me or {{company_name}}.

5. All charges will be processed in {{currency}}.

Signature Block

_____________________________

Cardholder Signature

Date: {{signature_date}}