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Credit Card Authorization Form
GCI-Card authorization form
Download
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
I (Name of authorized person)
*
, give permission to Grace Computer & Internet Corp to charge my card for the following purchases. My card details will be stored in my profile and will only be used for approved purchases.
Amount Authorized
*
Cardholder Email
Product/Service
*
Contact Phone
*
Credit Card Type
*
Mastercard
VISA
Discover
American Express
Cardholder (Name on Card)
*
(as shown on credit card)
Terms of Agreement
*
I authorize Grace Computer & Internet Corporation for auto-payments on the agreed authorized GCI services provided
To cancel, contact: info@gracecomputer.net (For example, cancellations must be received 1 week prior to expected billing date)
Date Authorized
*
Authorize Charges For:
*
One-Time
Monthly
Annually
(Also Remember to Select Period During PayPal Payment Page)
Verification
*
I verify all information inputted above is correct
Clicking Submit will Proceed to SECURE Payment Page, Select One-time or Recurring
Submit
