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Credit Card Authorization Template
Clearly document cardholder consent for one-time or recurring credit card charges in a simple authorization form.
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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:
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.
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]
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Easy-to-understand jargon
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Details
Learn more about
Credit Card Authorization Template
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
CREDIT CARD AUTHORIZATION TEMPLATE FAQ
What is a credit card authorization form?
A credit card authorization form is a written document where a cardholder gives a business permission to charge their credit or debit card. It records the card details, the amount or billing terms, and the cardholder’s consent, usually confirmed by a signature and date.
When should I use a credit card authorization form?
You should use a credit card authorization form whenever you need clear proof that a customer agreed to a card charge, especially for phone/email orders, deposits, advance payments, or recurring/subscription billing. It can help reduce disputes by showing that the cardholder approved the transaction.
Is a credit card authorization form the same as an invoice or contract?
No. An invoice shows what is being billed, and a contract describes the overall business deal. A credit card authorization form only focuses on the cardholder’s permission to charge their card based on agreed terms. It can be used together with quotes, contracts, invoices, or service agreements.
What should a credit card authorization template include?
A good credit card authorization template includes: cardholder and merchant information; card type and last digits; amount and currency; one-time or recurring billing terms; a brief description of the goods or services; cancellation rules for recurring charges; and a signature with date.
Is a signed authorization form enough to prevent chargebacks?
A signed form is helpful evidence but does not guarantee that a chargeback will never happen. Card networks and banks make their own decisions under their rules. The form simply gives stronger proof that the cardholder consented to the charge.
Can AI Lawyer help me customize this credit card authorization template?
Yes. AI Lawyer can help you adjust this template for your business by refining the wording, adding your logo or specific billing policies, and aligning it with your subscription or deposit terms. You still set the prices and rules and remain responsible for compliance with card network and local legal requirements.
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