Credit Card Recurring Payment Authorization Form printable pdf download

Golder Bail Bonds Inc.

319 Chapanoke Rd. Suite 110

Raleigh,NC 27603

Credit Card Recurring Payment Authorization Form

Schedule your payments to be automatically charged to your credit card. Just complete and sign this

form to get started!

Recurring Payments Will Make Your Life Easier:

•

It’s convenient (saving you time and postage)

•

Your payment is always on time (even if you’re out of town), eliminating late charges

Here’s How Recurring Payments Work:

You authorize regularly scheduled charges to your Visa, MasterCard, American Express or Discover card.

You will be charged each billing period for the total amount due for that period.

You agree that no prior-

notification will be provided if the total payment is under $500.00. If your bill is more than that amount, or

the payment date changes, you will receive notice from us at least 10 days prior to the payment being

collected.

Please complete the information below:

I ______________________________authorize

Golder Bail Bonds Inc.

to charge my credit card

(full name)

indicated below on the ____________ of each

___________________

for payment of my Bail Bond .

(day or date)

I understand that I will only receive advance notice of the charge if it exceeds

$5000.00.

Billing Address: ____________________________

Phone#________________________

City, State, Zip: ____________________________

Email : ________________________

Account Type:

Visa

MasterCard

Amex

Discover

Cardholder Name ____________________________________________

Account Number

____________________________________________

Expiration Date

_______________

CVV (3 digit number on back of Visa/MC, 4 digits on front of AMEX) ____________

SIGNATURE

DATE

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined

above. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next

business day. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit

card and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the

terms indicated in this authorization form.

Credit Card Recurring Payment Authorization Form

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