Auto Charge Payment Enrollment Form
Credit Card
Instruction : Please print and complete the blank fields.
provide a photocopy front and back of the your credit card
I, the undersigned, being a credit card holder of your company I wish to
enroll to your auto debit payment/ auto charge facility. I give you the
authority to pay all my bills under my account and in turn charge the same
to my credit card account. In case my credit card limit is not adequate to
absorb my bills, the dealer shall have the recourse to collect directly from
me.
Card Type : [ ] Visa [ ] MasterCard [ ] American Express [ ] ______________
Card number : ____________________________________
Credit Card Company : _____________________________________________
Expiration : Month __________________ Year
________
Name on Card : ___________________________________________
Billing Address : ________________________________________
________________________________________
________________________________________
________________________________________
zip code _______________
I hereby authorized _____________________________________________________
to charge the credit card shown above. I understand this is a non-refundable charge. This
authorization is valid on a continuing basis unless cancelled by myself in writing.
Card Holder Signature : ___________________________________
Name : ____________________________________
Date Today: _____________ Email _______________
Contact no. __________________________Birthdate : ________________