Recurring payment authorization form
Name
*
First Name
Last Name
ID Number or Contract Number
*
Phone Number
-
Area Code
Phone Number
Enter an email address and we will email you a receipt when payment is run.
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I am authorizing Cardinal Leasing to charge the amount below from my account for the first 4 payment on my rental agreement.
*
The 1st payment is authorized to be made on
*
-
Month
-
Day
Year
Date
Payment Type
*
Credit Card
Bank ACH
Credit Card Number
Card Expiration Date
CIV Code
Bank Routing Number
Bank Account Number
For Bank draft include account verification from the bank that includes your name and address along with your account number.
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of
Signature
*
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