Payment Authorization

Pay Authorization Form

Schedule your payments to be automatically charged to your credit card or withdrawn from your bank account.

Here’s How Payments Work

You authorize regularly scheduled charges to your Visa, MasterCard, American Express, Discover card or bank account. You will be charged on the agreed upon date(s) each month or you agree to process payment whenever payment is due. A receipt will be sent to you and the charge will appear on your credit card statement or bank statement.

Prefered Payment Method(Required)

Withdraw from Bank Account (no surcharge)

Charge Debit Card (no surcharge)

Charge Credit Card (4% surcharge*)

*Please be aware that credit cards will have a surcharge of 4% to your payment. This surcharge is not greater than our total cost of accepting credit cards. There is no surcharge for debit card payments. By authorizing the payment of your bill, you are authorizing us to charge your credit card with a 4% surcharge, subject to our terms of service and privacy policy.

Bank Withdraw Method

Fill out only if you've selected "Withdraw from Bank Account" method.

Account Holder Name

First Last

Bank Name

Routing Number

Account Number

Account Type

Business

Personal

What is the payment for:

Prepaid Services

Balance on the Account

Other

If 'Other' please explain:

Card Payment Method

Fill out only if you've selected either "Debit" OR "Credit" card method.

Card Holder Name

First Last

Card Number

CVV

Expiration Date

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Information

Contact Information(Required)

Street Address City State ZIP Code

Preferred Method of Contact(Required)

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Best Time to Call You

Authorization

I authorize the above named business to charge the credit/debit card or bank account indicated in this authorization form according to the terms outlined above. 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. 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. 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 scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form. I also understand that if payment is declined, an additional charge may be assessed for the additional work involved in obtaining correct payment information.

Your Name(Required)

First Last

Date(Required)