Credit Card Authorization Form

Credit Card Authorization Form

Lisa M Nardi P.C.
I, First Name Last Name , authorize Lisa M Nardi P.C. to charge my credit card for any past due amounts owed for services rendered. I understand that my card will only be charged if my account is past due.
- Charge Amount: The amount if any past due balance as of the billing date.
- Billing Date: The first day of each month following the due date of the unpaid invoice.
Card Type*

VisaMaster CardAmerican Express
Terms and Conditions:
1. I understand this authorization will remain in effect until I cancel it in writing and I agree to notify Lisa M Nardi P.C. in writing oif any changes in my account infirmation or termination of this authorization at least 15 days prior to the next billing date.
2. If the above noted payment dates falls on a weekend or holiday, I understand that the paymens may be executed on the next business day.
3. In the case of a transaction being rejected for Non-Sufficient Funds (NSF) I understand that Lisa M Nardi P.C. may at its discretion attempt to process the charge again within 30 days, and I agree to an additional $35 charge for each attemot returned NSF, which will be initiated as a separate transaction from the authorized recurring payment.
4. I acknowledge that the origoination of credit card transactions to my account must comply with the provisions of U.S. Law.
5. I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card companu; so long as the transactions correspond to the terms indicated in this authorization form.
Signature*

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Date*

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Date
If you have any questions regarding this authorization, please contact us at:
- Phone: 708-280-0279
- lmnbpc@gmail.com
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