2 - Credit Card Authorization Form

Credit Card Authorization Form

By signing this form you give Dropdown permission to debit your account weekly for your resident contribution in the amount of Dropdown. This is permission for a recurring transaction to your account that can be terminated by the signee upon one weeks notice to management. By signing below, you are also agreeing to the following one time move-in fees that will be charged to this card/bank account. One-time fees include nonrefundable security deposit (1 week) and drug testing / administration fee ($450). This card / bank account will be charged with any house penalties incurred during residency.

 

If placing payment for bedhold, reoccuring charge of 185$/week will be charged until intake into B-House Sober Living, during intake resident will be charged initial 450$(Admit/Drug test) costs, also 370$(Security Deposit). Bed Hold Payments are NON-REFUNDABLE, if resident chooses to not move in.

Name: Client first name Client last name

Date: Date

Signature: Signature

 

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CREDIT CARD INFORMATION 

Payee Name: Text field

Resident Name: Text field

Account Type: Checkboxes CheckboxesCheckboxes Checkboxes 

Cardholder Name: Text field

Card #: Text field

Expiration Date: Text field

CVV2 (3 Digit # on back of Visa/MC, 4 Digit on front of AMEX): Text field

Card Billing Address: Paragraph

Zip Code of Billing Address: Text field

Payee Phone Number: Text field

Email Address: Client email 

NAME: Client first name Client last name
SIGNATURE Signature DATE Date

I authorize the above named business to charge the credit card / bank account indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above for the amount indicated above only. I certify that I am an authorized user of this credit card / bank account and that I will not dispute the payment with my credit card company / bank, so long as the transaction corresponds to the terms indicated in this form.

 

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.