ACCOUNT_JOB_COMPANY

Payment Authorization Form

Schedule your payment to be automatically charged to your debit / credit card subject to the terms and conditions outlined in this Payment Authorization Form (the "Form").

• You authorize regularly scheduled charges to your card.
• You will be charged each billing period for the total amount due for that period.
• A receipt will be emailed to you and the charge will appear on your credit/debit card statement.
• You agree that no prior-notification will be provided to you for each scheduled payment

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Please complete the information below:

I, CUSTOMER , authorize ACCOUNT_JOB_COMPANY to charge my debit/credit card as indicated below [monthly / bi-monthly/ annually]  for the payment of CHARGE. The account details are stated below.

Billing Address:

Phone number:

City, State: 

Email:

Debit / Credit Card 

 Visa  Master Card   Amex   Cardholder Name _________________________ Expiration Date ____________ CVV (3 digit number on back of Visa/Master Card, 4 digits on front of AMEX):

SIGNATURE:

DATE:

• I authorize the ACCOUNT_JOB_COMPANY to charge the my credit/debit card as indicated above and in accordance with this Form 
• 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. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termination of this authorization at least 10 days prior to the next billing date.

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