Your Company Name

Client Name: [Client Print Name]

Service Address: [Client Address]

This Payment Authorization Form authorizes [Your Company Name] to automatically charge your credit card for your ongoing cleaning service subscription.

Subscription Details:

• Subscription Tier: [Name of Subscription Tier]
• Cleaning Frequency: [Weekly, Bi-weekly, Monthly, etc.]
• Price per Cleaning: [Amount]

Payment Authorization:

I hereby authorize [Your Company Name] to charge my credit card for the amount stated above on a recurring basis according to the chosen cleaning frequency. This authorization will remain in effect until cancelled by me in writing.

Credit Card Information:

• Cardholder Name: [Client Name] (as it appears on the card)
• Billing Address: [Client Billing Address]
• Card Type: (Visa, Mastercard, etc.)
• Card Number: [-][-][-][-] (omit middle digits for security)
• Expiration Date: [MM/YY]
• CVV Code: [-][-][-]* (last three digits on the back of the card)

Rules and Regulations:

• Subscription Changes: You may change your subscription tier or frequency by notifying [Your Company Name] in writing at least [Number] business days before your next scheduled cleaning.
• Late Payment Fee: A late payment fee of [Amount] will be applied to any payment received more than [Number] days past the due date.
• Service Cancellation: You may cancel your subscription at any time by notifying [Your Company Name] in writing at least [Number] business days before your next scheduled cleaning. Please note that no refunds will be issued for unused portions of a prepaid subscription period.

Liability Waiver:

The client acknowledges that [Your Company Name] and its employees will take all reasonable precautions to avoid damage to the client's property while performing cleaning services. However, the client agrees to waive and release [Your Company Name] from any and all liability for any damages caused by the cleaning services, except to the extent that such liability cannot be waived under applicable law.

Client Signature: _________________________

Date: [Date]

Please keep a copy of this form for your records.