Introducing Referent – AI-native practice management software for modern law firms.
Explore ReferentBusiness / Merchant Name: [Business / Merchant Name]
Business Address: [Business Address], [City], [State/Province], [ZIP/Postal Code], [Country]
Phone: [Business Phone Number]
Email: [Billing Email Address]
Website: [Website URL]
Who is authorizing the charge: [Cardholder Full Name]
What is being charged: [Brief Description of Goods and/or Services]
Where the transaction is associated: [Location / Department / Online storefront name]
When the charge will occur: [Date of Charge or First Charge Date]
Why the charge is due: [Invoice / deposit / subscription / balance due]
How the customer approved: [Select: signed form / email confirmation / portal confirmation]
Cardholder Name: [Cardholder Full Name (as it appears on the card)]
Billing Address: [Street Address], [City], [State/Province], [ZIP/Postal Code], [Country]
Phone: [Cardholder Phone Number]
Email: [Cardholder Email Address]
Type of Card: [Select: Visa / Mastercard / American Express / Discover / Other: Card Type]
Card Number: [XXXX-XXXX-XXXX-XXXX]
Expiration Date: [MM/YY]
Security Code: [XXX]
Name of Issuing Bank: [Bank Name]
Authorization Type: [Select: One-Time Charge / Recurring Charges]
Authorized Amount (one-time): [Amount and Currency]
Recurring Charge Amount (if recurring): [Amount and Currency]
Billing Frequency (if recurring): [Weekly / Monthly / Quarterly / Annually / Other]
Start Date (if recurring): [Start Date]
End Date or Until Cancelled (if recurring): [End Date or “Until Cancelled”]
Maximum Amount Per Billing Period (if applicable): [Maximum Amount and Currency]
Charge Authorization: [Cardholder authorizes Business / Merchant Name to charge the card listed in this form]
Authorized User Confirmation: [Cardholder confirms they are the authorized cardholder or authorized user]
Statement Descriptor: [Descriptor / Business Name as it appears on card statements]
Billing Information Updates: [Cardholder will promptly communicate changes to card details or billing information]
Cancellation Notice Email: [Billing or Support Email Address]
Cancellation Notice Mailing Address: [Billing Department Address]
Cancellation Effective After: [Number] business days from receipt of written notice
Charges Already Processed: [Charges processed or in progress before the effective time may still be applied]
Allocation entries: [If one charge applies to multiple invoices/orders, list them here]
Invoice/Order/Account # | Description | Amount Applied | Currency |
[Reference #] | [Invoice or order description] | [Amount] | [Currency] |
[Reference #] | [Invoice or order description] | [Amount] | [Currency] |
[Reference #] | [Invoice or order description] | [Amount] | [Currency] |
[Reference #] | [Invoice or order description] | [Amount] | [Currency] |
Invoice/Order/Account # | Description | Amount Applied | Currency |
[Reference #] | [Invoice or order description] | [Amount] | [Currency] |
[Reference #] | [Invoice or order description] | [Amount] | [Currency] |
[Reference #] | [Invoice or order description] | [Amount] | [Currency] |
[Reference #] | [Invoice or order description] | [Amount] | [Currency] |
Invoice/Order/Account #
Description
Amount Applied
Currency
[Reference #]
[Invoice or order description]
[Amount]
[Currency]
Attached Documents: [Select: invoice copy / receipt / service agreement excerpt / email confirmation]
Attachment Identifier: [File name(s) / link(s) / folder path]
Internal Reference: [Customer ID / ticket ID / case ID]
Cardholder Signature: [Signature]
Printed Name: [Cardholder Full Name]
Date: [Date]
Business Approval (Billing Lead): [Name / Title / Signature / Date]
Business Approval (Procurement or Finance): [Name / Title / Signature / Date]
Invoice/Order/Account # | Description | Amount Applied | Currency |
[Reference #] | [Invoice or order description] | [Amount] | [Currency] |
[Reference #] | [Invoice or order description] | [Amount] | [Currency] |
[Reference #] | [Invoice or order description] | [Amount] | [Currency] |
[Reference #] | [Invoice or order description] | [Amount] | [Currency] |
Each template already follows legal structure and best practices.
The agreement is automatically filled and adapted to your inputs.
Check the generated document, make edits if needed, and download a ready-to-use agreement.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Frequently asked
Use a reference number in the goods or services section and, if needed, add an allocation table showing how the authorized amount is applied across multiple invoices or orders. This makes it easier for the cardholder to recognize the charge and for the business to reconcile payments. It also helps if a customer later asks which invoice was paid, because the authorization record and the accounting record point to the same identifiers.
Whether you collect it depends on your payment workflow and your processor’s practices. If you include a field, keep it limited to what your process actually uses and avoid adding unnecessary data. If the charge is processed through a secure portal, you may not need to store the code on a paper form at all. The form can still document consent through amount, schedule, and signature even if some details are handled through another secure channel.
A contract describes the broader deal, including deliverables, responsibilities, and remedies, while an authorization form focuses narrowly on permission to charge a specific card on stated terms. Many businesses use both: the contract sets the commercial relationship, and the authorization form documents payment consent. If a customer asks why they are being charged, the contract explains the obligation and the authorization form shows the payment method approval.
The descriptor should match what will appear on the cardholder’s statement as closely as possible. When the descriptor is unfamiliar, customers are more likely to question or dispute the charge. Include a descriptor field so the business can align internal naming with the customer-facing statement line. If your descriptor varies by brand or location, use a placeholder that captures the exact version used for processing.
You can, but only if the form clearly states the amounts and timing for both charges or defines a recurring schedule that covers them. If the final amount is not known, consider authorizing a maximum amount per billing period and tying it to an invoice issued later. Clarity matters because cardholders typically expect the authorization to mirror the pricing they agreed to.
Update the card details and keep the original authorization record linked to the updated information, typically by noting an internal reference or creating a refreshed authorization tied to the same subscription. The important point is that the consent remains clear: what is being billed, how often, and how cancellation works. Keeping a record of when the update was provided helps avoid confusion about which card was authorized at which time.
Retention depends on your internal policies and the need to support reconciliation or dispute questions. Whatever period you choose, keep it consistent and ensure the authorization can be retrieved along with the related invoices, receipts, and any cancellation notice. The template’s record index fields are designed to make that retrieval easier by capturing where the documents are stored and the internal reference used to locate them.
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