Credit Card Authorization Form

One Time Payment ( $ 2,000.00 one-time payment)

Monthly Payment ( $ 20.00 for each month )

Quarterly Payment ( $ 60.00 for each three months )

Yearly Payment ( $ 240.00 for each year )

Payment Method

ConditionText
I, {cardholderName}, as a cardholder, hereby authorize ABC Company to charge my credit card for {conditiontext} and confirm that the information for the credit card and billing address is complete and accurate.

I have been informed that I can cancel the recurring payment at least 15 days before the payment by phone or signing a consent form provided by the merchant company.
Date

Month Day Year
Date
Cardholder Signature

Clear
Should be Empty: