Credit Card Authorization Template

[Business / Merchant Name]
[Business Address]
[City, State/Province, ZIP/Postal Code, Country]
Phone: [Business Phone Number]
Email: [Billing Email Address]
Website: [Website URL]

CREDIT CARD AUTHORIZATION FORM

1. Cardholder Information

Cardholder Name (as it appears on the card):
[Cardholder Full Name]

Billing Address:
[Street Address]
[City, State/Province, ZIP/Postal Code, Country]

Contact Details:
Phone: [Cardholder Phone Number]
Email: [Cardholder Email Address]

2. Card Details

Type of Card (check one):
☐ Visa
☐ Mastercard
☐ American Express
☐ Discover
☐ Other: [Card Type]

Card Number: [XXXX-XXXX-XXXX-XXXX]
Expiration Date (MM/YY): [MM/YY]
Security Code (CVV/CVC): [XXX]
Name of Issuing Bank: [Bank Name]

3. Authorization Type and Amount

Select one option and complete the details:

A. One-Time Charge
☐ I authorize a one-time charge to my card.

Authorized Amount: [Amount and Currency]
Date of Charge: [Date]

B. Recurring Charges
☐ I authorize recurring charges to my card.

Regular Charge Amount: [Amount and Currency]
Billing Frequency: [Weekly / Monthly / Quarterly / Annually / Other]
First Charge Date: [Start Date]
Final Charge Date or “Until Cancelled”: [End Date or “Until Cancelled”]

Maximum Amount Per Billing Period (if applicable): [Maximum Amount and Currency]

4. Description of Goods and/or Services

Description:
[Brief Description of Goods and/or Services]

Related Invoice / Order / Account Number (if any):
[Reference Number]

5. Authorization and Agreements

By signing below, I:

1. Authorize [Business / Merchant Name] to charge my credit/debit card listed in this form for the amounts and on the schedule indicated above.

2. Confirm that I am the authorized cardholder or an authorized user on this account.

3. Understand that charges may appear on my statement under the name [Descriptor / Business Name as it appears on card statements].

4. Understand that for recurring charges, this authorization will remain in effect until the earlier of:

   • the Final Charge Date stated in Section 3; or

   • my cancellation of this authorization in accordance with Section 6.

5. Agree that any changes to my card details or billing information will be promptly communicated to [Business / Merchant Name].

6. Cancellation and Changes (Recurring Charges)

For recurring charges, the cardholder may cancel this authorization by providing written notice to:

Email: [Billing or Support Email Address]
Mailing Address: [Billing Department Address]

The cancellation will take effect after [Number] business days from receipt of the notice. Any charges already processed or in progress before that time may still be applied.

7. Cardholder Signature

I have read and understood this Credit Card Authorization Form. I agree to its terms and authorize the charges as described.

Cardholder Signature: _________________________________

Printed Name: [Cardholder Full Name]

Date: [Date]

8. For Business Use Only

Internal Reference / Customer ID: [Internal Reference]
Processed By (Name or ID): [Staff Name/ID]
Date Received: [Date]
Notes:
[Internal Notes, if any]