Credit Card Billing Authorization Form

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

Credit Card Billing Authorization Form

I, {{customer_name}}, residing at {{customer_address}}, hereby authorize {{company_name}} to charge my credit card for payments as detailed below. This authorization is for either recurring payments or a single payment, as indicated.

Customer Information

Customer Name: {{customer_name}}

Customer Address: {{customer_address}}

Customer Phone: {{customer_phone}}

Customer Email: {{customer_email}}

Payment Details

Description of Goods/Services: {{description_of_services}}

Amount: {{currency}} {{amount}}

Payment Frequency: {{payment_frequency}} (e.g., monthly, quarterly, one-time)

Start Date (for recurring payments): {{start_date}}

End Date (for recurring payments, if applicable): {{end_date}}

Credit Card Information

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

Cardholder Name: {{cardholder_name}}

Card Number: {{card_number}}

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

CVV/CVC (for one-time payments or initial setup): {{cvv_cvc}}

Authorization and Agreement

I authorize {{company_name}} to initiate charges to my credit card account identified above. I understand that this authorization will remain in effect until I cancel it in writing, or until all authorized payments have been made.

I certify that I am an authorized user of this credit card and will not dispute payments with my credit card company, so long as the transactions correspond to the terms indicated in this authorization form.

I agree to pay a late fee of {{late_fee_percentage}}% per month on any outstanding balance if payments are not successfully processed due to insufficient funds or other issues with my credit card.

Cancellation Policy

This authorization can be cancelled by submitting a written request to {{company_name}} at least {{notice_period}} days prior to the next scheduled payment date. Cancellation requests should be sent to {{cancellation_email_address}} or {{company_address}}.

Signature

_____________________________

Customer Signature

Date: {{date}}