CREDIT CARD AUTHORIZATION FORM

ACCOUNT BILLING INFORMATION

First Name *

Last Name *

Customer ID

Billing: Street Address *

Billing: City *

Billing: State *

Billing: Zip Code *

Email Address *

Phone Number *

Cell Phone Number *

Comments/Notes Concerning This Authorization: *

SITE SERVICE ADDRESS

Site: Street Address *

Site: City *

Site: State *

Site: Zip Code *

CREDIT CARD INFORMATION

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

SERVICE TYPE

Select service type and billing frequency.

	Pool Service		Salt Service			WHRO Service
	- Monthly -		- Monthly -	- Bi-Monthly -		- Monthly -	- Annually -
Select All That Apply	- Monthly -		- Monthly -	- Bi-Monthly -		- Monthly -	- Annually -

I HEREBY AUTHORIZE WATER MEDIC OF CAPE CORAL INC. TO CHARGE MY CREDIT CARD AT THE INTERVAL STATED ABOVE FOR THE FOLLOWING AMOUNT: *

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. *

	Yes	No
I HEREBY AUTHORIZE WATER MEDIC OF CAPE CORAL INC. TO CHARGE MY CREDIT CARD FOR REPAIRS	Yes	No

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. *

clear

Form Signed on: * +

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