NY Credit Card Authorization Form

NY Credit Card Authorization Form

OneTime Credit Card Payment Authorization Form
Sign and complete this form to authorize Northeast Family Services to make a one time debit to your credit card listed below.

By signing this form you give us permission to debit your account for the amount indicated. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.
Client Name:*

First NameLast Name
Cardholder Name:*

First NameLast Name
Cardholder Phone Number:*
Email:*
This payment is for therapy received on this date:*

MonthDayYear
Payment Amount:*

Payment Amount:*

USD

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

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.
Cardholder Signature:*

Clear
Today's Date:*

MonthDayYear
Should be Empty: