JWFC Credit Card Authorization Form

Name
Credit Card Authorization Form
Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until canceled.
Credit Card Information
Card Type

MasterCardVISADiscover
Cardholder Name (as shown on card)
Card Number
Card Expiration Month:
Card Expiration Year:
Cardholder ZIP Code (from credit card billing address)
I authorized Jordan West Family Counseling to initiate electronic withdrawals, in the

preauthorized amounts and timing, from my card account ending in, of which I am the authoized signer.
Last 4 Digits
Last 4 Digits
I understand a receipt will be emailed to me confirming this StoredPay activation and for each subsequent StoredPay transaction.

I understand that I can cancel StorePay at anytime at HTTPS://myproviderlink.com or by contacting Jordan West Family Counseling.
EMAIL
example@example.com
EMAIL

Clear
Date

MonthDayYear
Date
Should be Empty:

Credit Card Authorization Form