Recurring Payment Creditcard Authorization Form

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What to put in a credit card authorization form for receiving current payments?

Recurring Payment Authorization Form

  • Schedule your payment to be automatically deducted from your bank account, or charged to your Visa, MasterCard, American Express or Discover Card. Just complete and sign this form to get started!
  • Recurring Payments Will Make Your Life Easier:
    • It’s convenient (saving you time and postage)
    • Your payment is always on time (even if you’re out of town), eliminating late charges
  • Here’s How Recurring Payments Work:
  • You authorize regularly scheduled charges to your checking/savings account or credit card. You will be charged the amount indicated below each billing period.
  • A receipt for each payment will be emailed to you and the charge will appear on your bank statement as “{{Name Childcare Systems}}Debit.
  • You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.
  • Please complete the information below:
  • I authorize {{Name Childcare Systems}}to charge my credit card
  • (full name) indicated below for $19.95 on the of each month for payment of my subscription.
  • Billing Address, Phone#  
  • City, State, Zip, Email   

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