RI Credit Card Payment Authorization Form

Credit Card Payment Authorization Form
Please complete all fields below:
Client Name:*

First NameLast Name
Cardholder Name:*

First NameLast Name
Phone Number:*

Area CodePhone Number
Email:
example@example.com
Account Type:*

VisaMasterCardAMEXDiscover
I authorize Northeast Family Services to charge my credit card account indicated below for charges associated with therapy appointments.
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. 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.
Signature:*

Clear
Date:*

MonthDayYear
Date

Payment Amount*

USDDescription

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country