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Recurring Credit Card Authorization Form

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The recurring credit card authorization form is a document that will authorize a company (ie: utility bills, various subscriptions, automobile payments etc.) to automatically deduct payment from an individual’s bank account or credit card account. The payments will be charged at the end of each bill’s, billing cycle. By providing permission for recurring payments, you will be charged on or around the same time each month until either the payments end because the purchase has completed or until permission has been removed by the cardholder.

How to Write

Step 1 – Download the authorization document – begin by entering the following information:

  • Carefully review the authorization statement
  • If the cardholder is in agreement enter the cardholder’s name
  • Submit the name of the merchant who shall receive permission to regularly charge the credit card
  • Enter the amount to be charged to the account
  • Provide the day
  • Enter the frequency in which there will be a withdrawal (ie: week, month, etc.)

Step 2 – Billing Information – Submit:

  • Cardholder’s billing address
  • City, State, Zip Code
  • Telephone number
  • Email address

Step 3 – Card Details – Enter:

  • Check the box next to the preferred payment method
  • Cardholder’s name
  • Account or CC number
  • Expiration date in mm/yy format (located on the front of the card)
  • CVV security number located on the back of the card (3 or 4 digit number)
  • The Zip Code associated with the credit or debit card

Step 4 – Cardholder’s Final Authorization and Signature –

  • The cardholder must read the authorization statement at the end of the form
  • Enter the name of the company to be notified, in the event automatic payments will no longer be provided or in the event of any changes
  • Provided that the cardholder agrees to the final paragraph the cardholder must provide their signature
  • Date of signature in mm/dd/yyyy format


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