Client Billing | VisionAmp Web Design

CLIENT BILLING FORM

CONTACT INFORMATION

Company Name

Contact Name

Phone Number

Billing Address

City

Zip

PAYMENT INFORMATION

Payment Amount

Description

PLEASE CHOOSE ONE

One Time Payment

Recur Monthly on 1st

Recur Monthly on 15th

PLEASE CHOOSE ONE

ACH (Bank Draft)

EFT (Credit Card)

(ACH) AUTOMATED CLEARING HOUSE WITHDRAW - BANK INFORMATION

Account Name

Bank Name

Account Number

Routing Number

(EFT) ELECTRONIC FUNDS TRANSFER - CREDIT CARD INFORMATION

Name as it appears on the card

Credit Card Number

Expiration Date

CVV # (3 on back of card) *AMEX is 4 digits on front of card

I hereby authorize VisionAmp:

I hereby authorize VisionAmp Marketing to initiate debit entries to the account(s) indicated below via Automated Clearing House (ACH) or electronic funds transfer (EFT). I hereby authorize the financial institution(s) named below to accept and honor withdrawals by VisionAmp Marketing. I understand that beginning on the date listed above, VisionAmp Marketing will begin withdrawals from my bank or credit card account. Such withdrawals will continue each month until the entire balance, provided to VisionAmp Marketing is paid in full. I understand that VisionAmp Marketing is debiting funds from my account for payment to VisionAmp Marketing.

Client Signature

Date