Credit Card Payment Authorization Form

Sign and complete this form to authorize Quality Waterproofing to make a debit to your credit card listed below. 3% fee charged to invoices over $3000.00.

By signing this form, you give us permission to debit your account for the amount indicated on or after the indicated date. This permission is for the transaction detailed below only, and does not provide authorization for any additional debits beyond this transaction.

Please complete the information below:

I (full name)Invalid Input authorize Quality Waterproofing to charge my credit card for the amount stated in the proposal as follows: 1/3 upon acceptance and remaining balance due upon completion of work at (job address)Invalid Input.

Payment Information

Payment Amount Invalid Input
Account Type Invalid Input
Cardholder Name Invalid Input
Credit Card Number Invalid Input
Expiration Date (MMYY) Invalid Input
CVC (3 Digit Code) Invalid Input

Billing Address

Street Address Invalid Input
City Invalid Input
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SIGNATURE Invalid Input
DATE Invalid Input

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

(Please only click the Submit button once.)