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  • Auth For AutoPayment

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    Andrea Bejarano
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    This document is an authorization form for automatic payments to be made from a credit or debit card to Liberty Power. It requests the cardholder's name, card number, expiration date, CVV number and signature to allow Liberty Power to charge monthly fees due to the card on the payment due date or following business day. The authorization can be withdrawn by the cardholder or terminated by Liberty Power with written notice.

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    Auth for AutoPayment

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    This document is an authorization form for automatic payments to be made from a credit or debit card to Liberty Power. It requests the cardholder's name, card number, expiration date, CVV number and signature to allow Liberty Power to charge monthly fees due to the card on the payment due date or following business day. The authorization can be withdrawn by the cardholder or terminated by Liberty Power with written notice.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    7 views1 page

    Auth For AutoPayment

    Uploaded by

    Andrea Bejarano
    This document is an authorization form for automatic payments to be made from a credit or debit card to Liberty Power. It requests the cardholder's name, card number, expiration date, CVV number and signature to allow Liberty Power to charge monthly fees due to the card on the payment due date or following business day. The authorization can be withdrawn by the cardholder or terminated by Liberty Power with written notice.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Please 

    complete and send by secured fax to: 1‐866‐577‐4628 Case# _______ 

    Authorization for Automatic Payments   

     
    Name as it appears on the card        ‰ One Time Payment                ‰ Recurring Monthly Payment 

    Card Type  Expiration Date (MM/YYYY)     
     
    ‰ VISA          ‰ MASTERCARD   
    Card Number      CVV2 (last 3 digits on the back of the card)   

    I authorize LIBERTY POWER to initiate charges for monthly fees due against the above referenced card. This authorization is for payments I am obligated to 
    make under my Agreement with LIBERTY POWER. The charges will be made on the payment due date or the following business day. I may withdraw this 
    authorization by giving written notice to LIBERTY POWER in such time and manner as to afford a reasonable time to act upon the request. Similarly, LIBERTY 
    POWER may terminate this agreement with me by written notice.   
     
    ________________________________________________________________        ____________________________________________________   
    Cardholder’s Signature                                                                                                  Date                                                                                                                  

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