Jazel Recurring Payment Authorization Form

Jazel Recurring Payment Authorization Form – Credit Card

Schedule your payment to be automatically deducted from your Visa, MasterCard, American Express or
Discover Card. Recurring payments occur on or shortly after the first of the month unless otherwise
indicated in your agreement(s). One-time payments for set-up fees, partial month site launch prorations or
other requested ad-hoc services will be processed in accordance with the terms outlined in your
agreement(s).

Company Name*
Billing Contact Name*
Billing Phone*
Billing/Invoicing Email*

Invoices will be sent to this email address
Card Information
Card Type*
Visa, Mastercard, AMEX, or Discover
Card Number*
Expiration Date*
CSV/Security Code*
Cardholder Name*
First Last
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Consent*
The following consent authorizes Jazel, LLC to charge my credit card according to the terms outlined in your agreement(s). I certify that I am the authorized user of the credit card account listed on this form and that I will not dispute the payment with my bank or credit card company; so long as the transaction corresponds to the terms of our agreement(s). Invoices will be sent electronically and charges will be deducted the same day. I understand that these withdrawals will be made every month throughout the term of the agreement(s) or until I give you written notice to terminate this credit card authorization method. I understand that my election to terminate this credit card authorization may require up to six (6) banking days to process and become effective

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Jazel Recurring Payment Authorization Form

Card Information