Automatic Credit Card Billing Authorization Form

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Automatic Credit Card Billing Authorization Form

If you would like to enjoy the convenience of automatic billing, simply complete the CREDIT CARD information section below and sign the form. ALL requested information is required. Upon approval, we will automatically bill your credit card for the amount indicated and your total charges will appear on your monthly credit card statement. You may cancel this automatic billing authorization at any time by contacting us.

Contact Information

Customer Name:__________________________________________________

Customer Account Number: _________________________________________

Phone: ______-__________-_____________

I authorize AVSS to automatically bill the credit card listed below as specified.

Amount $ _______ Frequency (Check only one) Weekly :___Monthly:___Quarterly:__Annually:_____

Start Billing on ____ / ____ / ______ End Billing when : Contract Expires___ Customer Provides Cancellation____

Credit Card Information (to be completed by customer)

AVSS accepts the following credit cards: VISA, Master Card, Discover, American Express

Credit Card Type:_________________ Credit Card Number:_____________________________________ Expires :______/_______

Cardholders Name(as shown on credit card):________________________________________ Cardholders Zip code (Required) :______________

Card Holders Signature: ______________________________________________ Date:_____________________

Must be mailed to : AVSS
5112 77th Place NE Suite 200
Marysville, WA 98270

Faxed forms will not be accepted