Credit Card Authorization Form Sample Clauses

Credit Card Authorization Form. As a Client of ViewPointe Executive Suites, LLC (“ViewPointe”), I, , authorize ViewPointe to charge the credit card listed below, for any and all fees associated with the Services outlined in the Virtual Office Services Agreement. If, after a payment by credit card, you later dispute the charges, unless prohibited by law, you agree not to cancel, revoke, charge back, or dispute any previously entered charge on your credit card. If you do so, and it is later determined that the charge was properly authorized, you agree to pay all out of pocket fees and costs incurred by ViewPointe as a result of the improper cancellation, revocation, charge back, or dispute. Type of Card: VISA MASTERCARD AMERICAN EXPRESS Credit Card Number: _ Expiration Date: CVC Code: (last 3 digits on back of Visa/MasterCard, 4 digits on AMEX) Credit Card Billing Name and Address: Name on Card: Street Address: City: State: Zip: Telephone: E-mail address:
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Credit Card Authorization Form. If you are a customer that pays by Credit Card you must sign a credit card authorization form. • PHOENIX MOBILE AIR, INC. only accepts Visa and MasterCard.
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Credit Card Authorization Form. I hereby authorize Xxxxxx Xxxxx, MA, LPC-Intern to maintain a record of my credit card and my signature on file for payment of the following services: psychotherapy services, including deductibles, co-pays, non-cancelled or late- cancelled appointment fees, any charges owed that are not covered by my insurance company, and the litigation policies that are set forth in the Informed Consent Agreement. These charges include, but are not limited to, payment of retainer for court/deposition/legal proceeding preparation and appearance, consultation and telephone appointments, report and letter writing, and completion of disability paperwork. My signature below authorizes Xxxxxx Xxxxx, MA, LPC-Intern to charge my credit card for all applicable charges on an on-going basis. I understand that if I decide to terminate services with Xx. Xxxxx, and my account is paid in full upon termination, I may withdraw the authorization to charge my credit card in the future. In the event your credit card expires, or is lost or stolen, of if you desire to use another credit card, please notify us and we will have you complete a new Credit Card Authorization Form, and will shred your old information. We are equipped to utilize Health Savings Account cards, and accept MasterCard, Visa, Discover and American Express. PLEASE PRINT LEGIBLY: Client Name: Cardholder’s Name (as it appears on the credit card): Credit Card Billing Address (the address where the credit card statement is received) Street Apt/Suite City and State Zip Code Credit Card Type Visa MasterCard Discover AMEX
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Credit Card Authorization Form. As a Client of Premier Office Suites, LLC, (“Premier”), I , authorize Premier to charge the credit card listed below, for any and all fees associated with the Services outlined in the Virtual Office Services Agreement. If, after a payment by credit card, you later dispute the charges, unless prohibited by law, you agree not to cancel, revoke, charge back, or dispute any previously entered charge on your credit card. If you do so, and it is later determined that the charge was properly authorized, you agree to pay all out of pocket fees and costs incurred by Premier as a result of the improper cancellation, revocation, charge back, or dispute. Type of Card: Visa MasterCard Amex Discover Credit Card Number: Expiration Date: CVC Code: (last 3 digits on back of Visa/MasterCard, 4 digits on AMEX) Credit Card Billing Name and Address: Name on Card: Street Address: City: State: Zip: Telephone: Signature: Premier Office Suites, LLC Virtual Office Services Agreement
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Credit Card Authorization Form. 2020-2021 Pleasecomplete all fields. You may cancel this authorization atany time by contacting us. This authorization will remain ineffectuntil cancelled. *Please note: Additional transaction fees will be applied to credit card payments. 3.8% fee on VISA, MC, DISC, 4.25% on AMEX *Fees subject to change throughout the year* Credit Card Information Card Type: ☐ MasterCard ☐VISA ☐ Discover ☐ AMEX Cardholder Name (asshown on card): Card Number: Expiration Date (mm/yy): Cardholder ZIP Code (from credit card billing address): I, , authorize Holy Trinity Catholic School to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions onmy account. Print Name Date
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Credit Card Authorization Form. I hereby authorize NME Surveillance LLC to charge my credit card for: • Start-up fees; • Alarm Monitoring Service(s) • Alarm Installation and Equipment; • Service Call Charges and Alarm Components; • Programming Changes; • Requested reports; • Recovery Charges of Proprietary Account Data Belonging NME Surveillance LLC; □ Visa □ MasterCard □ American Express (add 3%) Cardholder: Credit Card billing address: (code back of card) Card Number: 3 or 4 digit code Expiration date: Email address for electronic receipt: Authorized Signature:
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Credit Card Authorization Form. Note: Only fill out the following information if you are paying with a credit or debit card. Name as it appears on credit card: Credit Card#: Expiration Date: Total Amount Authorized to Charge# $ Visa [ ] MasterCard [ ] Discover [ ] American Express [ ] I, , authorize THE INVESTIGATIVE FIRM, INC. to charge the above credit, or debit card the amount listed amount for professional investigative services. I understand that a copy of my signature will remain on file and this document will be used to authorize future charges if I verbally request additional services. By executing and faxing a copy of this agreement to the undersigned you acknowledge that the agreement herein contained may be concluded by fax, and that signatures contained on electronic facsimiles hereof shall be binding as though actually made in person upon this document by the person signing the same. Client Signature: Date
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Credit Card Authorization Form. Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until canceled. Credit Card Information Card Type: □MasterCard □VISA □Discover □AMEX □Zelle □Venmo □Cash App □PayPal □Other: Cardholder Name (as shown on card): Card Number: Expiration Date (mm/yy): Cardholder ZIP Code (from credit card billing address): Auto Pay Bank Institution: Routing Number: Account Number: I, , authorize to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account. Customer Signature Date Xxxxxx Xxxxxx Above the Rest Academy
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Related to Credit Card Authorization Form

  • ACH Authorization Merchant authorizes Service Provider to initiate debit/credit entries to the Designated Account, the Reserve Account, or any other account maintained by Merchant at any institution, all in accordance with this Agreement. This authorization will remain in effect beyond termination of this Agreement. In the event Merchant changes the Designated Account, this authorization will apply to the new account.

  • Authorization, Etc This Agreement and the Notes have been duly authorized by all necessary corporate action on the part of the Company, and this Agreement constitutes, and upon execution and delivery thereof each Note will constitute, a legal, valid and binding obligation of the Company enforceable against the Company in accordance with its terms, except as such enforceability may be limited by (i) applicable bankruptcy, insolvency, reorganization, moratorium or other similar laws affecting the enforcement of creditors’ rights generally and (ii) general principles of equity (regardless of whether such enforceability is considered in a proceeding in equity or at law).

  • Authorization for Agreement The execution and performance of this ---------------------------- Agreement by Licensee and Manager have been duly authorized by all necessary laws, resolutions or corporate action, and this Agreement constitutes the valid and enforceable obligations of Licensee and Manager in accordance with its terms except as such enforceability may be limited by creditors rights laws and general principles of equity.

  • Card Information Updates and Authorizations If you have authorized a merchant to xxxx charges to your card on a recurring basis, it is your responsibility to notify the merchant in the event your card is replaced, your card information (such as card number and expiration date) changes, or the account associated with your card is closed. However, if your card is replaced or card information changes, you authorize us, without obligation on our part, to provide the updated card information to the merchant in order to permit the merchant to xxxx recurring charges to the card. You authorize us to apply such recurring charges to the card until you notify us that you have revoked authorization for the charges to your card. Your card is automatically enrolled in an information updating service. Through this service, your updated card information (such as card number and expiration date) may be shared with participating merchants to facilitate continued recurring charges. Updates are not guaranteed before your next payment to a merchant is due. You are responsible for making direct payment until recurring charges resume. To revoke your authorization allowing us to provide updated card information to a merchant, please contact us.

  • AGENT AUTHORIZATION FORM I/We, (Print Bidder name) , Do hereby authorize (print agent’s name), , to act as my/our agent to execute any petitions or other documents necessary to affect the CONTRACT approval PROCESS more specifically described as follows, (IFB NUMBER AND TITLE) , and to appear on my/our behalf before any administrative or legislative body in the county considering this CONTRACT and to act in all respects as our agent in matters pertaining TO THIS CONTRACT. Signature of Bidder Date STATE OF FLORIDA ) ) ss: COUNTY OF ) The foregoing instrument was acknowledged before me by means of ☐physical presence, or ☐online notarization, this day of , 20 , by [NAME OF PERSON], as [TYPE OF AUTHORITY,… e.g. officer, trustee, etc.)] for [NAME OF PARTY ON BEHALF OF WHOM INSTRUMENT WAS EXECUTED]. ☐Personally Known; OR ☐Produced Identification. Type of identification produced: . [CHECK APPLICABLE BOX TO SATISFY IDENTIFICATION REQUIREMENT OF FLA. STAT. §117.05] Notary Public My Commission Expires: (Printed, typed or stamped commissioned name of Notary Public) LEASED EMPLOYEE AFFIDAVIT I affirm that an employee leasing company provides my workers’ compensation coverage. I further understand that my contract with the employee leasing company limits my workers’ compensation coverage to enrolled worksite employees only. My leasing arrangement does not cover un-enrolled worksite employees, independent contractors, uninsured sub-contractors or casual labor exposure. I hereby certify that 100% of my workers are covered as worksite employees with the employee leasing company. I certify that I do not hire any casual or uninsured labor outside the employee leasing arrangement. I agree to notify the County in the event that I have any workers not covered by the employee leasing workers’ compensation policy. In the event that I have any workers not subject to the employee leasing arrangement, I agree to obtain a separate workers’ compensation policy to cover these workers. I further agree to provide the County with a certificate of insurance providing proof of workers’ compensation coverage prior to these workers entering any County jobsite. I further agree to notify the County if my employee leasing arrangement terminates with the employee leasing company and I understand that I am required to furnish proof of replacement workers’ compensation coverage prior to the termination of the employee leasing arrangement. I certify that I have workers’ compensation coverage for all of my workers through the employee leasing arrangement specified below: Name of Employee Leasing Company: Workers’ Compensation Carrier: A.M. Best Rating of Carrier: Inception Date of Leasing Arrangement: I further agree to notify the County in the event that I switch employee-leasing companies. I recognize that I have an obligation to supply an updated workers’ compensation certificate to the County that documents the change of carrier. Name of Contractor: Signature of Owner/Officer: Title: Date: INFORMATION FOR DETERMINING JOINT VENTURE ELIGIBILITY If the bidder is submitting as a joint venture, please be advised that this form MUST be completed and the REQUESTED written joint-venture agreement MUST be attached and submitted with this form. HOWEVER, IF THE BIDDER IS NOT A JOINT VENTURE, CHECK THE FOLLOWING BLOCK: ( ) NOT APPLICABLE

  • Information Release Authorization Throughout the Term, you authorize DES to obtain information from the DSP that includes, but is not limited to, your account name, account number, billing address, service address, telephone number, standard offer service type, meter readings, and, when charges hereunder are included on your DSP xxxx, your billing and payment information. You authorize DES to release such information to third parties, including affiliates that need to know such information in connection with your Retail Power service. These authorizations will remain in effect as long as this Agreement is in effect.

  • Obligor Notification Forms The Borrower shall furnish the Collateral Agent and the Administrative Agent with an appropriate power of attorney to send (at the Administrative Agent’s discretion on the Collateral Agent’s behalf, after the occurrence and during the continuance of an Event of Default or the Facility Maturity Date) Obligor notification forms to give notice to the Obligors of the Collateral Agent’s interest in the Collateral Portfolio and the obligation to make payments as directed by the Administrative Agent on the Collateral Agent’s behalf.

  • Authorization of Agreement, Etc The Borrower has the right and power, and has taken all necessary action to authorize it, to borrow and obtain other extensions of credit hereunder. The Borrower and each other Loan Party has the right and power, and has taken all necessary action to authorize it, to execute, deliver and perform each of the Loan Documents to which it is a party in accordance with their respective terms and to consummate the transactions contemplated hereby and thereby. The Loan Documents to which the Borrower or any other Loan Party is a party have been duly executed and delivered by the duly authorized officers of such Person and each is a legal, valid and binding obligation of such Person enforceable against such Person in accordance with its respective terms except as the same may be limited by bankruptcy, insolvency, and other similar laws affecting the rights of creditors generally and the availability of equitable remedies for the enforcement of certain obligations (other than the payment of principal) contained herein or therein may be limited by equitable principles generally.

  • Appointment and Authorization Each Bank irrevocably appoints and authorizes the Agent to take such action as agent on its behalf and to exercise such powers under this Agreement and the Notes as are delegated to the Agent by the terms hereof or thereof, together with all such powers as are reasonably incidental thereto.

  • Power; Authorization Such Investor has all requisite power and authority to execute and deliver this Agreement. This Agreement, when executed and delivered by such Investor, will constitute a valid and legally binding obligation of such Investor, enforceable in accordance with its respective terms, except as: (a) limited by applicable bankruptcy, insolvency, reorganization, moratorium and other laws of general application affecting enforcement of creditors’ rights generally; and (b) limited by laws relating to the availability of specific performance, injunctive relief or other equitable remedies.

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