Credit Card Recurring Payment Authorization Form printable pdf download

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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

You can get Rewards Points for paying your bill

Here’s How Recurring Payments Work:

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

card. You will be charged the amount indicate below each billing period. A receipt will be emailed to

you and each charge will appear on your statement. You agree that no prior-notification will be

provided unless the date or amount changes, in which case you will receive notice from us at least 10

days prior to the payment being collected.

Please complete the information below:

I ____________________________ authorize

to charge my credit card

(full name)

indicated below for

on the ________ of each

for payment of my

(day or date)

<insert type of

bill>.

Billing Address ____________________________

Phone# ________________________

City, State, Zip ____________________________

________________________

Account Type:

Visa

MasterCard

AMEX

Discover

Cardholder Name _________________________________________________

Account Number

_____________________________________________

Expiration Date

____________

SIGNATURE

DATE

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

above. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing

of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. 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 payment 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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