Automatic Credit Card Billing Authorization Form Automatic Credit Card Billing Authorization Form If you would like to enjoy the convenience of automatic billing, simply complete the Credit Card Information section below and sign the form. All requested information is required. Upon approval, we will automatically bill your credit card for the amount indicated and your total charges will appear on your monthly credit card statement. You may cancel this automatic billing authorization at any time by contacting us.Customer Name* Phone* Amount Frequency* Weekly Monthly Quarterly Annually Start billing on* MM slash DD slash YYYY End billing when* Contract Expires Customer provides written cancellation * I will call the office at (805) 643-4375 to give my credit card information. I want to receive a call from the office to give my credit card information. Signature*