Fill and Sign the Credit Authorization Form

Credit Card Charge Authorization Form _______________________________________ (Name of Vendor or Provider of Services) _______________________________________ (Street Address, City, State, Zip Code) _______________________________________ (Phone Number) Name on Customer’s Card___________________________________________ Credit Card Number______________________________________ Credit Card Type ______Visa ______ MasterCard ______ Discover Expiration Date ______________ CCV #_______ Billing Address _____________________________________________ _____________________________________________ _____________________________________________ Mailing Address (if different than billing address) _____________________________________________ _____________________________________________ _____________________________________________ The estimated total monthly usage for services/goods that the undersigned customer will be utilizing is $_________________. The undersigned customer agrees that he/she may choose to pay __________________ _________________________________ (Name of Vendor or Provider of Services) by check or credit card; however, the undersigned understands that _________________________________ __________________________ (Name of Vendor or Provider of Services) requires this credit card authorization to be on file with ________________________________________________ (Name of Vendor or Provider of Services) . The undersigned customer hereby authorizes _________________________________ ______________________________ (Name of Vendor or Provider of Services) to charge said credit card the amount due from customer to _________________________________________ _______________________________ (Name of Vendor or Provider of Services) if any payment to ___________________________________________________________ (Name of Vendor or Provider of Services) is delayed by more than 5 days from net invoice due date, whether the result of a failure or refusal to timely pay such charge or the return of a check for insufficient funds. Being the authorized cardholder, the undersigned customer agrees to the terms set forth in this agreement and specifically authorizes _________________________________________ ___________________________________ (Name of Vendor or Provider of Services) to charge my credit card, for the services/goods provided by _____________________________________ _________________________ (Name of Vendor or Provider of Services) . I understand that ____________________________________________________________ (Name of Vendor or Provider of Services) will provide me with an itemized monthly invoice detailing all of my charges. I further agree that in the event my credit card becomes invalid, I will immediately provide _______________________________________________________ (Name of Vendor or Provider of Services) with a new duly executed Credit Card Charge Authorization Form upon request, to be charged for the payment of any outstanding balance owed to _________________ _________________________________________ (Name of Vendor or Provider of Services) . I agree that I will not dispute any legitimate charges processed by __________________________ _________________________________________ (Name of Vendor or Provider of Services) . This authorization will remain in full force and effect until terminated, in writing, by the undersigned __________________________________ (Name on Card) . Witness my signature this _____________________________________ (date) . __________________________________________________ __________________________________________________ Name & Signature of Authorized Customer & Cardholder