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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)