Recurring Payment Authorization Form

Recurring Payment Authorization Form

You authorize regularly scheduled charges to your checking/savings account or credit card. You will be charged each billing period for the total amount due for that period. A receipt will be emailed to you and the charge will appear on your bank or credit card statement. If the payments date change, you will receive notice from us at least 10 days prior to the payment being collected.
Please complete the information below:
I,*
Full Name
Authorize Global Business Minds – Creativo Agency to charge my Credit Card or Bank Account Indicated below daily of each working day for payment for my service
- This payment is for Junk Cars Leads.
- Billing Information
Business Name*
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
- Credit Card Information
Card Type:*
Cardholder Name :*
(as shown on card)
Cardholder ZIP Code:*
(from credit card billing address)
SIGNATURE*

Clear
Date

MonthDayYear
Date
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Global Business Minds – Creativo Agency in writing of any changes in my account information or termination of this authorization at least 7 days prior to the next billing date. 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. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that Global Business Minds – Creativo Agency may at its discretion attempt to process the charge again within 3 days, and agree to an additional fee charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute the scheduled transactions with my bank or credit card company; provided the transactions correspond to the terms indicated in this authorization form.
Should be Empty: