Origence Credit Card Setup

Authorization for Credit Card Billing

Business Information

Legal Entity Name *

Doing Business As *

Seller Code *

Email Address *

Phone Number *

Business Address Line 1 *

Business Address Line 2

City *

State *

Zip Code *

Payment Information

INVOICE AUTOMATED BILLING AUTHORIZATION FOR CREDIT CARD PAYMENTS

1. I(we) herby authorize CU Direct Corporation("Company") to initiate credit card entries, effective date of this agreement, for payment of any fees owed by me (us) to Company from my (our) credit card named below.
2. I(we) agree that my (our) account will be debited on the tenth (10) day of every month or the next business day.
3. I(we) agree to notify Company in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date.

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Card Number *

Expiration *

CVV *

Cardholder First Name *

Cardholder Last Name *

Cardholder Phone Number *

I (we) understand that this authorization will remain in effect until I (we) cancel it in writing, and I (we) agree to notify CU Direct in writing of any changes in my (our) account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I (we) understand that the payments may be executed on the next business day. I (we) certify that I (we) am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.

Effective Date

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