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

Expiration Date

Security Code

(Back of Card)

Billing Information

Customer Name

First Last

Phone

Email

Address

Street Address Address Line 2 City 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 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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