Credit Card Authorization - VOICE1 LLC

Credit Card Authorization Form

Used to collect Credit Card information for automatic payment and payment fallback

Credit Card Authorization From

We require a valid and current credit card to remain on file. If you elect for ACH Automatic payments this card is used in the event an ACH payment is unable to be processed. Enrollment to ACH Auto-payment can be subscribed to via your online invoice.

Credit Card(Required)

VISA

Master Card

American Express

Discover

Card Number(Required)

CCV2(Required)

Month(Required)

Please enter a number from 1 to 12.

Year(Required)

Please enter a number from 20 to 30.

Name(Required)

Prefix First Middle Last Suffix

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Signature(Required)

I authorize VOICE1 LLC to charge my credit card for payment of services. If VOICE1, LLC is unable to process my payment; I will be responsible for an alternate payment arrangement and any resulting processing fees that may be incurred. A convenience fee of 3.5% may be added to transactions. This authorization is in effect until I notify VOICE1, LLC otherwise in writing. By signing this authorization, I acknowledge that I have read and agreed to all of the above information and warrant all information provided is true and correct. THIS AGREEMENT REMAINS IN EFFECT UNTIL CANCELED BY THE APPLICANT WITH WRITTEN NOTICE. The applicant, by providing VOICE1, LLC a written notice, may cancel this agreement at least 14 days in advance of the cancellation date.

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