Form Cvr 204 - Credit Card Authorization Form
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1Central Virginia Regional MLS
8975 Three Chopt Road
Richmond, VA 23229
TEL: 804-422-5000 Fax: 804-422-5086
Credit Card Authorization Form
Credit Card Type: Visa ___ Mastercard ___ AMEX ___ Discover ____Total Amount of Charge: $______________
Card # _______________________________________
Expiration Date: _____________
Name on Card: _________________________________________________________________
Signature: _____________________________________
Date:________________________
For Member Name: _____________________________
Member Number:____________________
I authorize the use of this card for this payment only & opt out CVR MLS free auto-pay service for
quarterly fees._____________________________________
_____________________________________________________________________________________________
Auto Debit/Credit Authorization Option
In addition to on line bill payment, CVR MLS offers an auto-pay service where quarterly fees can
be routinely charged to a debit or credit card. To set up this free service, please complete the
section below.
I
authorize the Central Virginia
Regional MLS to automatically charge my Debit/Credit Card account listed above for future fees
indicated below.
Please check:
[ ] Quarterly MLS Fees
Quarterly fees are posted and charged on the first business day of the month as indicated in the most
recent iteration of the CVR MLS Rules and Regulations.
[ ] I understand the following items concerning participation in this program.
•
An email confirming receipt and processing of this auto debit request will be sent to the email
address on file with CVR MLS. To check or update your email address, log into your online
member account at .
•
It is the responsibility of the card holder named above to notify the Association when
a credit card number or card expiration date has changed. Failure for the card to
process may result in loss of MLS and key services.
•
To view account information, verify payments and print receipts, log
into .
If you choose to discontinue your auto-pay service you must submit this request in writing to
•
CVR MLS at .
Signature
Date_______________
Email Address
___________________________________________________
For RAR Office Use: Processed By:___________________________________________ Date: ___________
_______ Initial Fees Processed
______ Auto Debit Info Sent to Accounting
CVR 204 Rev08.28.13
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