CREDIT CARD AUTHORIZATION FORM

ACCOUNT BILLING INFORMATION

SITE SERVICE ADDRESS

CREDIT CARD INFORMATION

SERVICE TYPE

Select service type and billing frequency.
Pool ServiceSalt ServiceWHRO Service
- Monthly -- Monthly -- Bi-Monthly -- Monthly -- Annually -
Select All That Apply

SERVICE RATES ARE SUBJECT TO CHANGE. CONSENT TO USE YOUR CREDIT CARD FOR PAYMENT PURPOSES IS, IN NO WAY A CONTRACT THAT GUARANTEES THE SERVICE COST FOR ANY DURATION OF TIME. YOU WILL BE NOTIFIED OF ANY RATE CHANGES AHEAD OF TIME.

ADDITIONAL USE OF CARD ON FILE

Your card can be used for payment purposes for other repairs. If you would like to use your card on file to pay for additional repairs incurred, please indicate below. *
 YesNo
I HEREBY AUTHORIZE WATER MEDIC OF CAPE CORAL INC. TO CHARGE MY CREDIT CARD FOR REPAIRS
I HEREBY ATTEST THAT I AM THE AUTHORIZED CARD HOLDER FOR THE ABOVE CREDIT CARD AND THAT I AM PERMITTED TO AUTHORIZE THE ABOVE REQUESTED CHARGES. I FURTHER ATTEST THAT THE INFORMATION PROVIDED ON THIS FORM IS ACCURATE AND I WILL BE HELD LEGALLY LIABLE FOR THESE CHARGES WHICH I HAVE AUTHORIZED TO BE PROCESSED WITHOUT MY PRESENCE OR FURTHER SIGNATURES REQUIRED. *
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