CAROLINA SMART HOME CARD AUTHORIZATION FORM

CUSTOMER AUTHORIZATION
Name on alarm account*

First NameLast Name
Name on Credit/Debit Card*
Card complete billing address (including city/state/zip)*
Card Holder's Contact Phone Number*
Reason for Payment*
Type of Payment*

One Time PaymentPayment PlanMonthly Reoccurring Payments
NOTES
I do hereby acknowledge that the above information is correct and that I am the authorized user (cardholder) of said credit/debit card account. I authorize BFD Carolina, Dba/Carolina Smart Home to charge my account using the merchant portal for the payment (s). All sales are final. Any payment declines may be subject to return fees.
SIGNATURE*

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DATE*

MonthDayYear
Date
THANK YOU FOR YOUR BUSINESS
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