Automatic Credit Card Billing Authorization Form 65

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

Customer Information ""(To be completed by merchant)""

Customer name:

Phone:

Payment Information ""(To be completed by merchant)""

I authorize Tanglewood Family Medical Center, PA to automatically bill the card listed below as specified.

Amount: Membership Fee

Frequency: Monthly

Start billing on: the 1st Day of the following month.

End billing when: Customer provides written cancelation.

Credit/ Debit Card Information ""(To be completed by customer)""

Tanglewood Family Medical Center, PA accepts the following credit cards:

Credit/Debit card number:

3 digit security code (on back)

(AMEX may be 4 digit code on front)

Expiration Date:

Cardholder's name:

(as shown on credit / debit card)

Billing Street Address

Cardholder's ZIP code

(from credit/debit card billing address)

Your Name:

Date

By checking this box, you agree that you have requested us to use the card provided on this form for automatic billing of your membership fee.

Your information will be encrypted.