I __________ authorize OfficeName to initiate the below one time transaction against the debit card account below. This authorization is to remain in full force and effect until any and all accounts associated with the customer name below are paid in full, or until I notify OfficeName in writing of my intent to cancel and/or rescind this authorization in such time as to afford OfficeName and the financial institution as a reasonable opportunity to act on it.
Amount: $MinDue
Date: CurrentDate
I __________ authorize
OfficeName to initiate the below transaction(s) against the credit /
debit card account below. I acknowledge this is pre-authorization to process the
credit / debit card payment(s) outlined below. This authorization is to remain in
full force and effect until any and all accounts associated with the customer name
above are paid in full, or until I notify OfficeName
in writing of my intent to cancel and/or rescind this authorization in such time
as to afford OfficeName and the financial
institution a reasonable opportunity to act on it. In the event that an attempted
credit / debit transaction is unsuccessful, I hereby authorize
OfficeName to re-attempt the transaction within 15 days of the original
payment due date.
Set Amount: $MinDue
One Time Transaction Date: CurrentDate
I __________ authorize
OfficeName to initiate the below transaction(s) against the credit /
debit card account below, according to the payment schedule listed herein. I acknowledge
this is pre-authorization to process the credit / debit card payments outlined below.
This authorization is to remain in full force and effect until any and all accounts
associated with the customer name above are paid in full, or until I notify OfficeName in writing of my intent to cancel
and/or rescind this authorization in such time as to afford
OfficeName and the financial instituation a reasonable opportunity to
act on it. In the event that an attempted credit / debit transaction is unsuccessful,
I hereby authorize OfficeName to re-attempt
the transaction within 15 days of the original payment due date.
For an amount between: $1.00 (minimum recurring payment) and $AmountBetween
(total amount due).
Recurring Transaction Basis:
Payment dates based upon the payment schedule of the attached contract.
Customer Full Name:
Phone: __________
Email: __________
Name on Card: __________
Card Number: __________
Expiration Date: __________
Billing Address: __________