Client Information:

Client Name: ___________________________

Client Address: ___________________________

City: ______________________ State: ________ Zip Code: _____________

Phone Number: ______________________ Email Address: _______________

Payment Method:

Please select the preferred payment method:

[ ] Credit Card: _________________________ (Card Number) [ ] Visa [ ] MasterCard [ ] American Express [ ] Discover

[ ] Debit Card: _________________________ (Card Number) [ ] Visa [ ] MasterCard [ ] American Express [ ] Discover

[ ] Bank Account: _________________________ (Account Number) [ ] Checking [ ] Savings

Authorization:

I, [Client's Name], hereby authorize [Your Company Name] to charge the above-selected payment method for the following services:

Description of Services:

[Describe the services for which the payment authorization is being provided, including any applicable fees or charges.]

Amount to be Charged:

The total amount to be charged is $____________.

Frequency of Charges:

[Specify the frequency of charges, e.g., one-time charge, monthly subscription fee, etc.]

Terms and Conditions:

  1. Authorization: By signing below, the Client authorizes [Your Company Name] to charge the selected payment method for the agreed-upon services.

  2. Liability Waiver: The Client acknowledges and agrees that the Company shall not be liable for any unauthorized charges resulting from the use of the authorized payment method.

  3. Cancellation Policy: The Client may cancel the authorization at any time by providing written notice to the Company.

Signature:

IN WITNESS WHEREOF, the Client has executed this Payment Authorization Form as of the Effective Date first above written.

[Client's Name]

By: _______________________________ Date: _____________