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Recurring CC Authorization

Cardholder Name

First Name

Last Name

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone

(###)

###

####

Credit Card Type

Visa

Mastercard

Discover

Amex

Credit Card Number

Exp. Date

CVC Code

Visa, MasterCard, and Discover - 3 Digit Code on Back of Card Amex - 4 Digit Code

Agreement

I authorize Salon Partners, LLC to charge the agreed amount listed below to my credit card provided herein on the agreed upon date/ dates listed below. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement. I understand that this authorization will remain in effect until my balance is paid in full. In addition, I agree to notify Salon Partners, LLC of any changes to my payment information at least 10 days prior to the next payment authorization period. (billing date). I am the authorized user of this payment card and will not dispute the scheduled payments outlined above.

Electronic Signature

Date

YYYY

Approved By:

First Name

Last Name

Member Login

Welcome, (First Name)!

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