Credit Card Authorization

Company Name: *

I hereby authorize the Company as shown above, hereinafter called COMPANY, to charge the credit card indicated in this authorization form. This payment authorization is for the goods/services offered by COMPANY for the amount indicated in this authorization form and is a recurring payment that will occur monthly. I certify that I am an authorized user of this credit card, and I will not dispute the payment with my credit card company, so long as the transaction corresponds to the information indicated in this form.

Card Holder Name: *

Billing Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Credit Card Number: *

Credit Card Type: *

Expiration Month *

Expiration Year *

Security Code *

Payment Amount: *

Frequency of Payments: *

Signature *

Date: *

Customer Full Name: *

Customer Title: *

Customer Phone #: *

Customer Email: *