Fillable Printable Credit Card Authorization Form - San Francisco

Credit Card Authorization Form - San Francisco

T h e B a r Association of San Fran c i s c o

C r e d i t Ca r d Authoriza t i o n For m

In order for The Bar Association of San Francisco (BASF) to accept and bill your credit card, please complete all fields below,

sign, date and fax to 415-782-8994. Please provide the following information as it appears in your order. All information

sent is strictly confidential and BASF adheres to the highest standards for account data protection.

Contact/Billing Information: (as shown on credit card)

Company: Contact Name:

Billing Address:

City: State: Zip:

Phone: Fax Number:

Email:

Credit Card Type:  Visa  MasterCard  American Express

Card holder name (as shown on credit card):

Credit Card #: Expiration Date:

Credit Card Security Code: Amount: (As per the Insertion Agreement)

Please Check the Appropriate Box(es):

 One Time Use: I hereby authorize The Bar Association of San Francisco (BASF) to charge the indicated credit card the

amount indicated above. This is a one-time charge authorization. I am not authorizing BASF to setup my account within a

recurring billing system - rather, I prefer to pay by check or money order on all future invoices I understand that if I want BASF

to charge any balances to my credit card in the future, I will need to submit another authorization form at that time or choose

the selection below.

Please list what the credit card authorization is for:

 Recurring Billing: I hereby authorize BASF to charge the indicated credit card on a periodic basis for the amount due under

my contract with BASF as indicated above. This Recurring Payment Authorization/Periodic Charge shall remain in force until

cancelled by me in writing.

Please list what the credit card authorization is for:

Authorization:

I hereby authorize BASF to charge the indicated credit card. I agree that this is either a one time or periodic charge that will be made as indicated above.

To terminate the recurring billing process, if selected, I must cancel in writing, otherwise the account will be manually invoiced and payment made via check,

money order or wire. I understand that all account cancellations must be made in writing. I will not dispute BASF’s recurring billing with my credit card issuer

so long as the amount in question was for services rendered prior to my canceling my account in the manner required. I guarantee and warrant that I am

the legal cardholder for this credit card and that I am legally authorized to enter into this one time or recurring billing agreement with BASF.

Signature of Card holder (Required): Date:

The Bar Association of San Francisco, 301Battery Street, Third Floor, San Francisco, CA 94111 Telephone: 415.782.9000 Fax: 415.782.8994

Attention:_______________________________________________________________________________