Recurring Credit Card Authorization

Ref No.: [Submission Reference]
Date: [Submission Date]

Customer Information

Name: [Field 4] [Field 5]
Address: [Address Line1 Field 7], [Address Line2 Field 8], [City Field 9], [State Field 10], [Zipcode Field 11], [Country Field 12]
Email: [Field 14]
Phone: [Phone Number Field 13]

Payment Information

Card Holder Name: [Field 17] [Field 18]
Credit Card Number: [Field 24]
Expiration Date: [Field 25]/[Field 26]

Authorization Terms

I, [Field 4] [Field 5], authorize XYZ Corporation to charge the credit card indicated in this authorization form according to the terms outlined herein. This payment authorization is for the goods/services described in the contract, for the amount indicated here, and it is valid for the recurring transaction of amounts owed for the duration of the contract.

You certify that you are an authorized user of this credit card and that you will not dispute the transaction with your bank; so long as the transaction corresponds to the terms indicated in this agreement.

Signature Date: [Field 23]