creditcardform saitta

Credit Card Processing and Authorization Form

Please fill out this form and submit it. By signing and completing this form, you authorize BreathEasy to charge your credit card for your website as outlined below and, if necessary, initiate adjustments for any transactions credited/debited in error. This authority will remain in effect until BreathEasy is notified by you in writing to cancel it (with 2 weeks notice All processing will be through Stripe.

Step 1 - Personal Information: Saitta Trudeau RV

Name PLEASE PRINT AS APPEARS ON CARD*

Street Address City State Zip Code*

(Phone Number)*

Email Address*

example@example.com

Please choose one*

VisaMastercardDiscoverAmex

Credit Card Number*

Expiration Date*

Date

Security Code*

Step 3 - Project/Pricing Information:

Design & Setup (USD): $516.17 Design $499 plus $17.17 convenience credit card processing fee Monthly Service $250.00 plus 9.71 convenience credit card processing fee Total due 6/1 $775.88 - recurring after will be the $259.71 Details of services for monthly expenses included on invoice sent initially. Any questions let us know.

Cardholder Signature*

Effective Date*

Date