Credit Card Authorization 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

Credit Card Authorization Form

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