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Credit Card Billing Authorization Form Templates Free Download

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Below is the Credit Card Billing Authorization Formtemplate body. If necessary, please put the personal information, company information, such as text to replace the specific content you need. you can download the .doc template file on the end of the article by click download link.

CREDIT CARD BILLING AUTHORIZATION FORM

Credit Card Billing Information:

[YOUR COMPANY NAME] / Name:


Person Authorizing:


Credit Card Type:
Visa [ ]
MasterCard [ ]
Amex [ ]
Discover / Novus [ ]
Other, please specify:

Issuing Bank:


Credit Card Number:


Enter CVC number:
Last 3 digits from the back of card or 4 digits from face of card.


Expiration Date:


Billing Address:


City:


State/Province:


Zip/Postal Code:


Country:


Phone Number:


Fax Number:


Please select one of the Following Payment Options:

Once
Bill my credit card once for the following amount:



Please apply this payment to the following Insertion Order/Invoice #


Monthly
Bill my credit card once per month for the amount of service provided each month for all contracts with [YOUR COMPANY NAME].



Applicant agrees that all information provided is accurate and complete. Applicant also acknowledges that all orders may be immediately terminated at [YOUR COMPANY]s discretion if any charges are declined or charge backs are claimed against any outstanding invoiced amount. Disputes to amounts invoiced should immediately be reported to [EMAIL ADDRESS].

Changes in the status of this card can also be reported to [EMAIL ADDRESS].





The undersigned is the duly authorized representative of the [YOUR COMPANY NAME] above.

Authorized Signature:              Date:         

click to download Credit Card Billing Authorization Form template

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