Recurring Payment Authorization Form
ADVERTISEMENT
1Recurring Payment Authorization Form
All requested information below is required to sign up for automatic recurring billing. Please
complete the information below & sign the form. Upon approval, we will automatically bill
your VISA or MasterCard for the amount indicated & your total charges will appear on your
credit card statement. You may cancel this automatic billing authorization at any time by
contacting us. Signed & completed forms should be mailed to Alive Ministries, Inc., PO Box
1424, Woodstock, GA 30188.
Customer Information
Customer Name_________________________________________________________________________
Email address _______________________________________ Phone ______________________________
Address_______________________________________________________________________________
(from credit card billing statement)
City ________________________________________ State _________________ Zip_________________
Payment Information
I authorize Alive Ministries, Inc. to automatically bill my card listed below as specified below.
I would like to sponsor ________ (enter quantity) families of the Save It Forward Food Pantries. It cost approx. $35 per
month to provide for each family.
I would like to sponsor ________ (enter quantity) envelopes for volunteers to shop with each week at an estimated cost
of $6 each. I understand that all of the food purchased will be donated to the Save It Forward Food Pantries.
I would like to set a specific amount of ________ to donate to Alive Ministries.
The total recurring amount to be charged to my card is _______________.
Quarterly
Frequency
Once
Weekly
Monthly
(check one)
Start on _________/_________/_________
End on ___________/___________/____________
Month
Day
Year
Month
Day
Year
No End Date
(circle if applicable)
Credit Card Information
Cardholder name _______________________________________________________CSC______________
(as shown on card)
(Card Security Code on back of card)
Card Number_________________________________________________ Expires ____________________
I understand that I will receive an email when my credit card is charged. (Make sure email address above is correct.)
___________________________________________________________ _________________________
Customer’s Signature
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business