Credit Card Change Request Form

Credit Card Change Request Form
Today's Date*

MonthDayYear
Date
Effective Date of Credit Card Change (Always the 1st of the month)*

MonthDayYear
Date
Client Name*

First NameLast Name
Client Email*
example@example.com
Cardholder Name

First NameLast Name
I, {cardholderName}, as a cardholder, hereby authorize CORE LEADERS, LLC to charge me for Coaching Services, in advance, on the 1st of every month via the payment method I have chosen. I confirm that the information for the credit card and billing address is complete and accurate.

I understand a credit card processing fee of a maximum of 3.5% will be assessed on my recurring monthly payments, if I have chosen credit card payments, to be paid by the client.

I have been informed that I can choose to cancel at any time by providing written notice of termination to coach@coreleaders.com a minimum of five (5) business days before the next monthly billing date.
Monthly Coaching Amount

$1500$2000$2500$3000$3500$4000$4500$5000
Credit Card Payment Details
Cardholder Name

First NameLast Name
Credit Card Number
Expiration Date Month/Year (MM/YY)
Security Code
Billing Address for Credit Card

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CORE Client Care Submitting Form (if applicable)

First Name Last Name
Should be Empty:

Credit Card Payment Details