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Credit Card Payment Authorization Form

Sign and complete this form to authorize Quality Waterproofing to make a debit to your credit card listed below.

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 card for work being done at (job address)Invalid Input as follows: the deposit amount per the terms of the contract upon contract acceptance, and the balance due upon completion. In the event my contract involves multiple scopes of work, I authorize Quality Waterproofing to charge my card for each individual scope of work line item as it is completed, regardless if all scopes of work are complete. Furthermore, in the event the work takes more than ten working days to complete, I authorize Quality Waterproofing to charge my card in multiple increments based on the percent of work that has been completed as determined by Quality Waterproofing in its sole discretion and professional opinion.

Payment Information

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Billing Address

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I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. 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.)