AUTO BILLING

Automatic Credit Card Billing Authorization Form

This form is for automatic billing, simply complete the Credit Card Information section below and sign the form. All requested information is required. Upon approval, we will automatically bill your credit card for the amount indicated and your total charges will appear on your monthly credit card statement.

Client Information

* Indicates required field

Business Name *

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Project Information

Project Name *

Briefly Describe The Project *

Payment Information

I authorize Bennett Creative Group to automatically bill the card listed below as specified:

Amount *

Frequency Of Payment *

Billing Start Date *

End Billing *

When Contract Expires (NOTE: If this is a website this will also remove the site when the contract expires) Customer Provides Written Cancelation

Credit Card Information

Credit Card Type *

Card Number *

Expiration *

CVV Code *

Card Holders Name (As shown on card) *

First

Last

Billing Address *

Line 1

Line 2

City

State

Zip Code

Country

Terms Of Agreement

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Bennett Creative Group (BCG) in writing of any changes in my account information or termination of this authorization at least 30 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an BCG Transaction being rejected for Non Sufficient Funds (NSF) I understand that BCG may at its discretion attempt to process the charge again within 30 days, and agree to an additional charge(s) for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the 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 with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form above.

I Agree To These Terms *

Yes I Agree

Signature *

Digital Signature Upload *

Max file size: 20MB

Submit