Credit Card Information - BreakThrough Counseling

Client's Credit Card Information and Authorization

Please provide credit card information and authorization for recurring charges.

Client Name

Type of Card (Visa/MasterCard/Etc)

Name as it appears on the card

Billing Address that matches card

Card #

Expiration Date

3 Digit Security Code

Cardholder Consent

I hereby authorize BCS to make repeating/recurring charges to my credit card indicated above for the collection of payment for all sums owed to BCS, and if necessary, to initiate and/or process adjustments for any transactions credited/debited in error. I certify that I am an authorized holder and user of the above-indicated credit card. I understand that charges on the above-indicated credit card will be made on a repeat/recurring basis as services are rendered to me, as long as this authorization remains in effect. I further agree that this authorization shall remain in effect until BCS is notified by me, in writing, to cancel or modify this authorization at least five (5) days before such change it to take effect. In the event any charges are declined or cannot be processed on the above-indicated credit card, I agree to pay for all outstanding charges within fifteen (15) days of the same becoming due. I understand BCS may charge a processing fee, as allowed by law, for any declined charges.

Cardholder Name

Date

Client's Credit Card Information and Authorization

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