AUTO BILLING

Automatic Credit Card Billing Authorization Form

This form is for automatic billing, simply complete the information. 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 / Website Name *

Briefly Describe The Project *

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. 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 *

Submit

Automatic Credit Card Billing Authorization Form

Client Information

Project Information

Credit Card Information

Terms Of Agreement

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