Center for Anxiety - Credit Card Authorization

Credit Card Payment Authorization Form

Sign and complete this form to authorize The Center for Treatment of Anxiety Disorders to make a debit to your credit card listed below. By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date.
Please complete the information below:
I authorize The Center for Treatment of Anxiety and Mood Disorders to chard my credit card for the below amount on or after the below date on this form.
Name

First Name Last Name
Amount
Date

Month Day Year
Date
Billing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Account Type

Visa MasterCard AMEX Discover
Cardholder Name (as it appears on your card)
Signature

Clear
Date

Month Day Year
Date
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
Should be Empty:

Credit Card Payment Authorization Form