Recurring Payment Authorization New Recurring Payment Authorization Intro to Recurring PaymentsRecurring payments will simplify your payment process: It’s convenient (saving you time and postage), and your payment is always on time (even if you’re out of town). Here’s how recurring payments work: You authorize charges to your credit card. You are charged the amount indicated on each Order Acknowledgement. A receipt for each payment will be emailed to you. You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us in writing prior to the payment being collected. Your payment can be automatically charged to your Visa, Mastercard, American Express or Discover card. Just complete and sign this form to get started!Company DetailsCompany NameAquabella Account NumberAquabella Branch- Select -New JerseyTampaPort Saint LucieOklahoma CityDallasHoustonLas VegasPhoenixSacramentoAnaheimJacksonvilleEmailPhonePlease Accept the Terms & Conditions: I authorize Aquabella to charge my credit card ending in the four digits entered below for the total amount of product orders as indicated on each Order Acknowledgement.Last Four Digits of the Card I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Aquabella in writing of any changes in my account information or termination of this authorization. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my credit card company; so long as the transactions correspond to the terms indicated in this authorization form.Your NameDateSignature Sign Here PreviousNextRecurring Payment Card Details Card InfoCard Type Visa Mastercard Amex DiscoverCardholder NameCompany AddressAddress Line 1Address Line 2CityStateZip CodeCredit Card NumerExpiration Date (MM/YYYY)CVC Previous Submit Form
