Auto Pay Credit Card Form

Auto Pay Credit Card Form

Authorization for Automatic Credit Card Payments
Account Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
I hereby authorize Hutchens Rentz-Eden to initiate a debit payment, from the credit card I will provide via telephone, for the payment of charges incurred at Hutchens Rentz-Eden. Debit payment from the credit card will be made the next business day after a delivery. Hutchens Rentz-Eden will furnish me with a receipt of any and all transactions.

This authorization is to remain in full force and effect until Hutchens Rentz-Eden has received written notification from me of its termination in such time and in such manner to afford Hutchens Rentz-Eden to act on said request. Cancellation of this authorization shall not terminate any of my payment obligations pursuant to the purchase and payment in full of products and services from Hutchens Rentz-Eden.

Card Number: Customer Service will call for credit card information one time only, at the time the initial invoice(s) is/are due. In keeping with the Red Flags Rule established by the Federal Trade Commission (FTC) and Payment Card Industry (PCI) compliance, all credit card information is stored with our credit card processor and not Hutchens Rentz-Eden.
Signature*

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Date*

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- What is a Credit Card Authorization Form?
  - A Credit Card Authorization Form is a form filled out by the credit card holder authorizing us to charge your credit card.
- Why We Use It.
  - We take this extra step to protect our customers as well as ourselves from credit card fraud. It also gives us a written record of your authorization for us to charge your card.
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