Credit Card Authorization Template: Recurring Charges & Consent

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].

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

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

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

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.

the Final Charge Date stated in Section 3; or

my cancellation of this authorization in accordance with Section 6.

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]