Credit/Debit Card Form
Account Information
Client Name
First
Last
Company Name
Pricing Structure
Use my Credit/Debit card for a ONE-TIME charge selected below. (plus tax)
Use my Credit/Debit card for a RECURRING charge selected below. (plus tax)
Recurring Charge is:
Weekly
Monthly
Quarterly
Annually
Start Billing On:
MM slash DD slash YYYY
End Billing When:
Contract expires.
Customer provides written cancellation.
Contract Expires:
(Required)
MM slash DD slash YYYY
Price to be Paid:
(Required)
Billing Notes:
Card Information
Name
Card Type
Card Number
We will confirm expiration date and security code by phone
Billing Information
Customer Name
First
Last
Phone
Email
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
My Shipping Information is the Same as my Billing
Yes
Shipping Information
Customer Name
First
Last
Phone
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Authorization
Authorization Agreement
I agree to this policy.
By signing this authorization, I agree to let Cucumber & Company charge my credit/debit card the noted amount on this form and any others.
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