Recurring Credit Card Payment Authorization Form

Recurring Credit Card Payment Authorization Form
I, {cardholderName}, as a cardholder, hereby authorize Eye Care Specialists to charge my credit card and confirm that the information for the credit card and billing address is complete and accurate.

I have been informed that I can cancel the recurring payment at least 15 days before the payment by phone or signing a consent form provided by the merchant company.

I, {cardholderName}, as a cardholder, hereby authorize Eye Care Specialists to charge my credit card on a monthly basis at the amount of indicated below.
Monthly Basis, please select
Card Type
Cardholder Name

First NameLast Name
Card Number
Expiration Date
Card Holder Zip Code
Date

MonthDayYear
Date
Cardholder Signature

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