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


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.


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

[Client's Name]

By: _______________________________ Date: _____________