CREDIT/CHARGE/DEBIT CARD PREAUTHORIZATION
Kate J. Heit, MA, LPC
Towne Square Professional Bldg. 303*277*9407 Office
5738 Olde Wadsworth Blvd. kjh1050@
Arvada, CO 80002
CREDIT/CHARGE/DEBIT CARD PRE-AUTHORIZATION
If you intend to use a credit/charge/debit card for fees, please complete this page.
I authorize Kate J. Heit, MA, LPC to keep my signature on file and to charge fees, or partial fees, to my credit, charge or debit card account for services provided to
_____________________________________________
Client Name: (please print)
I understand that this authorization is valid until canceled in writing. I understand that charges for ongoing services will normally be posted to my credit card account within a week of each service date.
I agree that if I have any problems or questions regarding charges to my account, I will contact Kate J. Heit for assistance. I agree that I will not dispute any charges with my credit card company unless I have first attempted to rectify the situation directly with
Kate J. Heit and those attempts have failed.
Cardholder Name (please print):
______________________________________________________________________________
Billing Address (where statements are mailed):
______________________________________________________________________________
City:__________________________________ State: __________ ZIP: __________________
Card Type (circle one): Visa MasterCard Discover
Account No.: __________________________________________________________________
Exp. Date: ______________ V-Code: ____________
(The V-Code is a 3–4 digit number on the back of your card, located after the account number).
Cardholder Signature: _______________________________________ Date: ____________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- debit cards geneseo
- implementing a credit debit card payment service
- credit debit card payment authorisation slip
- credit charge debit card preauthorization
- final rfp with debit cards government of new york
- lesson materials using debit cards
- thinking about implementing a point of sale pos credit
- ms archer s math class home
Related searches
- use debit card as credit
- debit card benefits
- debit card drawbacks
- debit card run as credit
- charging debit card as credit
- wells fargo debit card limit
- debit card payday loans
- xfinity visa debit card balance
- credit vs debit card comparison
- platinum debit card wells fargo
- key bank unemployment debit card balance
- debit card laws and regulations