Credit/Debit Card Payment Consent Form 

Client Name ____________________________________________________

.

Print Last

First

Middle Initial

Name on Card if different ___________________________________________
I authorize ____________________________ and ProfessionalCharges.com
.

Provider Name
to charge my card  for professional services for  

 

the amount of $__________________.
Type of Card: VISA  MasterCard.Discover Exp. Date __________
.
Card Number _______ - _______ - _______ - _______  CVV Number  ______
.
Card Holder's Billing Address for Monthly Card Statements
 
___________________________________________________________________
Street City State Zip
.
If I have questions about these charges, I agree to contact my provider and if necessary ProfessionalCharges.com via email (info@professionalcharges.com). I agree that I will not pursue a refund directly through my credit/debit card company, bank, or financial institution. If any of my actions yield a chargeback for any reason, I agree to pay any and all penalty fee(s) incurred by my provider.
Card Holder Signature ____________________________ Date ____ /____ /____

Charges may appear on your card statement as an abbreviation of ProfessionalCharges.com usually ProfCharges.com