Credit Card Billing Authorization Form

{{company_name}}

{{company_address}}

Phone: {{phone}} | Email: {{email}} | Web: {{website}}

Credit Card Billing Authorization Form

Credit Card Billing Authorization Form

Authorization Grant

I, {{cardholder_name}}, residing at {{cardholder_address}}, hereby authorize {{company_name}} to charge my credit card account for payments as described below. This authorization remains in effect until cancelled in writing either by myself or by {{company_name}}.

Payment Details

**Payment Type:** {{payment_type}} (e.g., Recurring Payments, One-Time Payment)

**If Recurring Payments:**

- **Frequency:** {{payment_frequency}} (e.g., Monthly, Quarterly, Annually)

- **Start Date:** {{start_date}}

- **End Date (if applicable):** {{end_date}}

- **Amount per payment:** {{currency_code}} {{amount_per_payment}}

**If One-Time Payment:**

- **Date of Payment:** {{payment_date}}

- **Amount:** {{currency_code}} {{one_time_amount}}

**Description of Goods/Services:** {{goods_services_description}}

Credit Card Information

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

**Cardholder Name (as it appears on card):** {{cardholder_name_on_card}}

**Card Number:** {{credit_card_number}}

**CVV/CVC:** {{cvv_cvc}}

**Expiration Date:** {{expiration_date}} (MM/YYYY)

Cardholder Agreement

I understand that this authorization allows {{company_name}} to process charges to my credit card account. 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 of this authorization.

I agree to notify {{company_name}} in writing of any changes to my credit card information or if I wish to revoke this authorization. I understand that any revocation will be effective within {{notice_period}} business days of receipt of my written notice.

I acknowledge that returned payments or chargebacks may incur additional fees as per {{company_name}}'s policies, which will be charged to my account.

Company Contact Information

For any queries or to revoke this authorization, please contact:

**Email:** {{company_email_for_queries}}

**Phone:** {{company_phone_for_queries}}

**Address:** {{company_address_for_queries}}

Signature

_____________________________ **Cardholder Signature**

_____________________________ **Date**

_____________________________ **Print Name**