Client Billing Authorization Form

"*" indicates required fields

It is understood and acknowledged that all monthly service clients must have an automated form of payment on file at all times. To that end, we hereby request that "Adentities, LLC" (Company) use the following automatic form of payment to pay for any amounts owed them.

Company Name*

Your Name*

Your Email*

Your Phone No.*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Pay with Bank Transfer Form

By default clients pay all agency fees via bank transfer / EFT

Account Type*

Routing/ABA Number (9 digits)*

Please enter a number from 100000000 to 9999999999.

Account Number*

Confirm Account Number*

Account Holders Name*

Are We Managing any type of Paid Ads Campaign (Google, FB, etc) For You?*

Yes

Credit Card for Ad Spend Only

Credit Card Authorization

Full Name of Cardholder*

Credit Card Billing Address*

Credit Card Billing City*

Credit Card Billing State*

Credit Card Billing Statement Zip Code*

Cardholder Phone Number*

Card Type*

VISA

MasterCard

American Express

Diner's Club

Credit Card Number*

CVV number*

3 digit verification code on the signature strip (4 for American Express)

Expiration Date (Month/Year)*

Client Authorization and Approval - Authorized Accountholder Signature*

Your Title*

Credit Card Authorization and Acknowledgement*

I understand that this authorization will remain in effect for 360 days minimum. I acknowledge that the organization of Credit Card transactions to my account must comply with the provisions of U.S law. I certify that I am an authorized user of this Credit Card and will not dispute these scheduled transactions.

Order Authorization & Acknowledgement*

I hereby agree to and authorize the use of the payment information provided for my/our account, and understand that all sales are final and payments rendered are final and strictly non-refundable. I acknowledge that I have read and accept all terms of the data services agreement, marketing services agreement on this site as well as the privacy policy and terms of service. I allow Adentities, LLC to charge my fees to my bank account on the specified dates.

Name

This field is for validation purposes and should be left unchanged.