Credit Card Billing Authorization Form

COMPANY LETTERHEAD

{{company_name}}

{{company_address}}

{{phone}}

{{email}}

{{website}}

CREDIT CARD BILLING AUTHORIZATION FORM

I, {{customer_full_name}}, hereby authorize {{company_name}} to charge my credit card indicated below for recurring payments/one-time payments as agreed upon. I understand that this authorization will remain in effect until cancelled by me in writing, or by {{company_name}}.

CUSTOMER INFORMATION

Customer Full Name: {{customer_full_name}}

Billing Address: {{customer_billing_address}}

City, Postal Code: {{customer_city_postal_code}}

Phone Number: {{customer_phone_number}}

Email Address: {{customer_email_address}}

CREDIT CARD INFORMATION

Card Type (Visa/Mastercard/Amex/Diners): {{card_type}}

Cardholder Name (as it appears on the card): {{cardholder_name}}

Credit Card Number: {{credit_card_number}}

CVV/CVC: {{cvv_cvc}}

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

AUTHORIZATION DETAILS

Please select one of the following:

[ ] RECURRING PAYMENTS: I authorize {{company_name}} to charge my credit card for recurring payments as per the attached agreement/invoice {{invoice_number}}.

Frequency: {{payment_frequency}}

Amount per payment: {{currency}} {{recurring_payment_amount}}

Start Date: {{recurring_start_date}}

[ ] ONE-TIME PAYMENT: I authorize {{company_name}} to charge my credit card for a single payment.

Amount: {{currency}} {{one_time_payment_amount}}

Description of Service/Product: {{payment_description}}

Date of Transaction: {{transaction_date}}

TERMS AND CONDITIONS

I understand that a _________________ (e.g., service fee, late payment fee) may be applied if payments are declined or returned.

I certify that I am an authorized user of this credit card 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.

I acknowledge that this authorization is for the purpose of efficient payment processing and does not alter any contractual agreements for goods or services provided by {{company_name}}.

I understand that to cancel this authorization, I must provide written notice to {{company_name}} at least {{notice_days}} days prior to the next scheduled payment date. Cancellation requests should be sent to {{cancellation_email_address}}.

ACKNOWLEDGEMENT

By signing below, I acknowledge that I have read, understood, and agree to the terms and conditions of this Credit Card Billing Authorization Form.

SIGNATURE BLOCK

_________________________________________

Cardholder’s Signature

_________________________________________

Printed Full Name

_________________________________________

Date: {{signature_date}}