Free credit card authorization form template 31Free credit card authorization form template 31
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Credit Card Authorization Form
(fill out, print, and sign the form)
Please complete and sign this authorization form. All fields are required. Your credit card will be billed
automatically for the amount indicated and charges will state COMPANY NAME on your statement. You may
cancel this automatic billing authorization with 30-days’ notice by contacting us in writing.
Customer Information
Customer Name

Telephone Number (include area code)

Payment Information
I authorize COMPANY NAME to charge the card listed below as follows:
Amount:

Frequency

Start billing on:

Monthly
or

Quarterly

□ immediately

Credit Card Information
Credit Card Type

__ Visa __ MasterCard __ Amex __ Discover __Other

Credit Card Number

CVV #

Expiry Date

Cardholder’s Name (as shown on credit card)

Billing Address

State
Zip Code

Cardholder’s Signature

Date

Fax this agreement to 123-123-4567
Or mail to: COMPANY NAME - 123Park Avenue, Michigan 69789 MI

Annually

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