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Card Authorization

This document contains a card authorization form for a consumer connect program. It requests the company name, contact information, credit card details including the card number, security code, expiration date and billing address. It specifies that the credit card will be charged up to a certain amount per week for each lead or appointment until written notice to cancel is received. The cardholder signs and dates the form to authorize the transactions and agrees that any disputes will go through arbitration rather than a chargeback, which would result in a $500 fine.

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dljenkins23
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446 views1 page

Card Authorization

This document contains a card authorization form for a consumer connect program. It requests the company name, contact information, credit card details including the card number, security code, expiration date and billing address. It specifies that the credit card will be charged up to a certain amount per week for each lead or appointment until written notice to cancel is received. The cardholder signs and dates the form to authorize the transactions and agrees that any disputes will go through arbitration rather than a chargeback, which would result in a $500 fine.

Uploaded by

dljenkins23
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

Card Authorization

Consumer Connect Program

Company Name: _____________________________________

Contact Phone Number: _______________________________

Company Email Address: ______________________________

Please mark the type of card you authorize for this transaction:
Visa___ MasterCard___ AMEX___ Discover___

Credit Card Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __

Security Code/ CVV2 Code : ____________ (three or four digit code on back or below
CC# in front)
Expiration date on Credit Card: ___________________________

Credit Card Statement Address (must match the address shown on credit card
statement).
_________________________________________________________
_________________________________________________________
_________________________________________________________

Phone number of Credit Card Holder: (_____)_____________________

Please charge this Credit Card $_______ per lead/appointment until I send you written
notice to quit. You may charge up to $______ total per week.
Current TV (Transaction Value): ________

Description of offer/question for prospective clients:


___________________________________________________________________________
___________________________________________________________________________

Name of cardholder: (signature) ____________________________________

Name of cardholder: (printed) _____________________________________

Date of signature: ______________________________

After acceptance into Consumer Connect Program, cardholder (and/or company) will be
provided with "test" contacts, if cardholder is unhappy with results Provider may
remedy/replace or issue refund. Cardholder is protected by money back guarantee, an
attempted chargeback will result in an immediate $500 fine to cardholder's card, this
agreement servers as Proof of Deliver and any and all problems that arise must be settled
through arbitration with stated attorney ________________________. This agreement may be
used in conjunction with Policies Agreement if provider chooses.

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