Credit Card (ACH) Authorization Form

Who are you?

I am a Business seeking to provide authorization forms for my customers.I am a Consumer seeking to provide authorization to a business.

Name

What is Your Name?

First

Last

Name of the Business

Type of Authorization

Is this for an ACH or Credit Card payment authorization?

Is this for an ACH or Credit Card payment authorization? ACHCredit CardBoth

ACH - Providing payment through an individual's checking or savings bank account.

Credit Card - Providing payment through an individual's credit card

Type of Payment

Is this going to be for a Recurring Charge or a One (1) Time Payment?

Is this going to be for a Recurring Charge or a One (1) Time Payment? Recurring ChargeOne (1) Time PaymentI Want the Option for Either

Recurring Charge - Occurs usually once per month on a specific date. The most common types are for Gym Memberships, Auto Insurance, etc

One (1) Time Charge - For an amount that must be paid immediately with the financial information provided by the customer cannot be used again for any future charges.

Recurring Charge

Do you know the recurring charge amount?

Do you know the recurring charge amount? YesNo

This is the amount ($) that will be charged to the Credit Card or Bank Account on a Recurring basis

What is the Amount to be charged to the Customer?

Payment Interval

Payment will be made every

week, month, etc.

Goods / Services

Do you wish to include a description of any services or goods rendered?

Do you wish to include a description of any services or goods rendered? YesNo

Describe the goods / services rendered:

NSF

What is the Fee for any Non Sufficient Funds (NSF)?

This is the fee for any payment that is attempted and not charged.

For ACH only

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