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Payment Authorization · Popular

Recurring Credit Card Payment Authorization Form

Securely collect cardholder consent for recurring billing with this easy-to-use payment authorization form template for businesses.

Use This Template Free Preview

Frost theme

formbuilder.ai/f/recurring-credit-card-payment-authorization-billing-agreement-form

Recurring Credit Card Payment Authorization & Billing Agreement Form

Cardholder Full Name

· · ·

Cardholder Email Address

· · ·

Cardholder Phone Number

· · ·

Submit

The Recurring Credit Card Payment Authorization & Billing Agreement Form is a professional template designed to help businesses collect secure, written consent from customers before charging their credit card on a recurring basis. It captures all essential cardholder information, credit card details, and billing schedule parameters in one streamlined form.

This template is ideal for subscription-based businesses, service providers, SaaS companies, gyms, nonprofits, and any organization that bills customers on a weekly, monthly, or annual basis. By documenting authorization in writing, businesses protect themselves legally while giving customers full transparency over their payment commitments.

With fields for card type, card number, expiration date, CVV, billing frequency, authorized payment amount, and end date, this form covers every detail needed for a compliant recurring billing agreement. Get started for free and customize it to match your brand and billing policies in minutes.

3 Pages

21 Questions

~7min To complete

Free No credit card needed

Field types Short Text ×4 Date ×4 Dropdown ×2 Full Name Email Phone Address number currency Single Choice Long Text singlecheckbox termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Cardholder Information 6 questions

Cardholder Information

1 Cardholder Full Name * Full Name

2 Cardholder Email Address * Email

3 Cardholder Phone Number * Phone

4 Billing Address * Address

Company / Merchant Details

5 Company or Merchant Name * Short Text

6 Account Number or Customer ID Short Text

Page 2 Payment & Billing Details 11 questions

Credit Card Information

1 Card Type * Dropdown

2 Card Number * Short Text

3 Name on Card (if different from cardholder) Short Text

4 Card Expiration Date * Date

5 CVV / Security Code * number

Recurring Billing Schedule

6 Authorized Payment Amount * currency

7 Billing Frequency * Dropdown

8 First Payment Date * Date

9 Authorization Duration * Single Choice

10 End Date (if applicable) Date

11 Description of Goods or Services Being Billed * Long Text

Page 3 Authorization & Agreement 4 questions

Authorization Agreement

By signing below, I authorize the above-named company to charge the credit card listed for the recurring amount and frequency specified. I understand that this authorization will remain in effect until I cancel it in writing, or until the specified end date, and that I agree to notify the company in writing of any changes to my account information or termination of this authorization at least 15 days prior to the next billing date. I certify that I am an authorized user of this credit card and that I will not dispute the scheduled recurring transactions with my credit card company, provided the transactions correspond to the terms indicated in this authorization form.

1 I acknowledge that I am the authorized cardholder and agree to the recurring charges as described above * singlecheckbox

2 I have read and agree to the cancellation policy and billing terms * termsandconditions

3 Date of Authorization * Date

4 Cardholder Signature * Signature

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.