Credit Card 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 sums owed them.

Company Name*

Your Name*

Your Email*

Credit Card Information

Full Name of Cardholder*

Cardholder Phone Number*

Credit Card Billing Address

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

Card Type*

Please Specify*

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 the duration of our service and product agreements, and that a 3% service charge fee will be added to all invoices paid by credit card. 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.

Any Additional Notes

Please describe why you're filling out this form and what the payment method being added is to be used for. Example: if you are using our services for two different campaigns, you may want to charge them on separate accounts for accounting purposes. For example, you may want to charge advertising on one account and website development on another. If this payment method is to be used for all campaigns/projects, you can specify in the box below or leave it blank.

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.

Credit Card Authorization Form

Credit Card Information

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