Credit Card form for Authorize.net. RECURRING

Fields marked with an asterisk (*) are required.

Credit Card form for Authorize.net. RECURRING

"*" indicates required fields

Your Name*

First Last

Name of Business or Organization*

Be sure to include the legal name, and, if applicable, any DBA. Example: WSJM Inc. d/b/a Mid-West Family.

Address*

Be sure this is the same address as your credit card.

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Be sure this is the same phone number as your credit card.

Your Email*

We will send you a copy of your payment confirmation here.

Invoice Number

Please provide the invoice number for reference, if available.

Referencing

Reference the product(s) or service(s) this payment is applying toward. Example: "2022 Annual Campaign"

This field is hidden when viewing the form

Name of Mid-West Family Representative*

Please provide, if known.

Recurring Charge Period*

Would you like to be charged monthly, or weekly?

Monthly (30 Days)

Weekly (7 days)

How Many Weeks or Months Should We Charge You?*

Please enter a number from 2 to 99.

Amount To Charge Your Account Each Period*

Start Date for Recurring Billing*

Your first payment will process beginning on this date and will determine the weekly or monthly schedule for your recurring payments.

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Signature*

By signing, I authorize Mid-West Family - Southwest Michigan (WSJM Inc.) to automatically deduct payment from my credit card to pay for my agreed contract with the company on a monthly basis. The authorization is to remain in effect through the term indicated on the form above. I understand that I am responsible for paying any additional invoices for services rendered outside of this invoice number or product contract not covered by this payment. If I need to make an adjustment to this schedule, I understand that I must contact the business manager within 5 business days of the next recurring payment date, that this current recurring schedule will be cancelled, and a new form will be filled out by my organization to begin a new schedule or payment amount.

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Credit Card form for Authorize.net. RECURRING

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