Card Authorization

Card Authorization Form

Card on File Permission
Please read and sign the following. This authorization will remain in effect until cancelled and can be withdrawn at any time by notifying Mission of Hope.
- I acknowledge that my card will be kept on file within Mission of Hope's payment system.
- I acknowledge that my card will be charged the full rate specified before or after each scheduled/agreed upon counseling session.
- I acknowledge that my card will be charged for any unpaid balance, including late cancellations and no show appointments.
- I acknowledge that I have the right to access all receipts indicating transactions that have been charged to my account at any time.
- I agree to notify the vendor in writing of any changes in my account information and/or termination of this authorization at least 15 days before the next scheduled billing charge date. If a payment/charge is rejected due to Non-Sufficient Funds (NSF) I also accept that the merchant may process the charge again within 30 days at their discretion and that an additional charge may be levied for each returned payment.
- I certify that I am the owner of the credit card described below and will not dispute the scheduled payments with my bank/credit card company, provided that the transactions correctly correspond with the terms written on this authorization form.
Please list ALL CLIENT names who have permission to use this card for appointment payments
Client Name*

First NameLast Name
Client Name

First NameLast Name
Client Name

First NameLast Name
Card Informaiton
Card Holder Name (If different from above)

First NameLast Name
Last 4 Digits on Card*
Expiration Date*

MonthDayYear
Date
Billing Zip Code
Should be Empty:

Card Authorization Form

Please list ALL CLIENT names who have permission to use this card for appointment payments

Card Informaiton