credit card ach payment authorization form

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Credit Card account bank account authorize Charge date Payment transaction Merchant

  
Credit Card / ACH Payment Authorization  
  
  
Check One (1) and Enter Your Details  
  
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❑ - Recurring Charge - You authorize regularly scheduled charges to your credit card or 
bank account. You will be charged the amount indicated below each billing period. A 
receipt for each payment will be provided to you and the charge will appear on your 
credit card or bank statement. You agree that no prior-notification will be provided unless 
the date or amount changes, in which case you will receive notice from us at least 10 
days prior to the payment being collected.  
  
I _______________________ authorize _________________________ to charge my   
                     (Full Name)                                                     (Merchant’s Name)   
Credit Card or Bank Account below for $________________ on the ______________   
                                                                                       (Amount $)                                     (day) of 
each ________________.  
               (week, month, etc.)  
  
This payment is for ________________________________.  
                                           (Description of Goods/Services)  
  
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❑ - One (1) Time Charge – Sign and complete this form to authorize the merchant below 
to make a one-time charge to your credit card or bank account listed below.    
  
By signing this form, you give us permission to debit your account for the amount 
indicated on or after the indicated date. This is permission for a single transaction only, 
and does not provide authorization for any additional unrelated debits or credits to your 
account.  
  
I _______________________ authorize _________________________ to charge my   
                    (Full Name)                                                      (Merchant’s Name)  
  
credit card or bank account indicated below for $_______________ on ____________.    
                                                                                                     (Amount $)                          (Date)  
  
This payment is for ________________________________.  
                                           (Description of Goods/Services)  
  
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Billing Information  
  
Billing Address ___________________________   Phone # ______________________  
  
City, State, Zip ___________________________   Email ________________________   
        
  
Bank (ACH)                                      Credit Card   
  
❑ Checking           ❑ Savings  
Name on Acct   
_______________  
Bank Name   
_______________  
Account Number  _______________  
Routing Number  _______________  
  
  
  ❑
 Visa                     ❑ MasterCard    
❑
 Amex                   ❑ Discover  
Cardholder Name  _______________  
Account Number  _______________  
Exp. Date                  _______ / _______  
CVV                       _______  
  
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the 
merchant in writing of any changes in my account information or termination of this authorization at least 
15 days prior to the next billing date. 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. For ACH debits to my 
checking/savings account, I understand that because these are electronic transactions, these funds may 
be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an 
ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that the merchant may at its 
discretion attempt to process the charge again within 30 days, and agree to an additional $_____ charge 
for each attempt returned NSF which will be initiated as a separate transaction from the authorized 
recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with 
the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account 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.   
  
  
  
BANK ACCOUNT / CARHOLDER’S SIGNATURE ___________________________             
  
DATE _____________________