Complete & sign this form to easily process your payments.

In an effort to better serve our clients and simplify your billing experience, our firm offers credit card acceptance. Charge card information is filed with your confidential client information and kept secure.
Client required to supply a copy, front and back, of the credit card and a copy of the Driver’s license of the person authorized on the card.

AUTHORIZATION

I hereby authorize (Portable Blowout) to charge the balance currently due on my account for the amount of $ Sales Order #

PAYMENT INFORMATION

Client Name

Client Email *

Client Billing Address *

City

State / Province / Region

Country

Zip Code

Type of Credit Card * VISAMASTERCARDDISCOVERAMERICAN EXPRESS

Card Number *

Expiration Date *

Security Code *

Card Holder Name *

Date

Attach Front & Back Credit Card Images *

CHARGE POLICY

Being the authorized cardholder or the Corporate Officer, by signing above I understand and agree to the terms set forth in this agreement, agree to pay, and specifically authorize to charge my credit card for the services and or products provided. I further agree that in the event my credit card becomes invalid, I will provide a new valid credit card upon request, to be charged for the payment of any outstanding balances owed. I furthermore confirm that I have received all services and goods to satisfactory conditions.

Charges made for actual services performed by our office are non-refundable. In the event of pre-payment any unused funds will be refunded within 30 days.

I acknowledge and agree that the cost includes 3% Credit Card Fee.

Credit Card Authorization

AUTHORIZATION

PAYMENT INFORMATION

CHARGE POLICY