Credit Card Pre-Authorization Form

CUSA Care Medium
5433-M Clayton Road, Clayton, CA 94517
Tel: 925-672-9989

**** WHERE the Credit Card Bills Go ****

Credit card information is filed confidentially by encrypted algorithms with Converge card services.
You are authorizing charges to your card only for the expressed purposes below.

Name on Card (Print): _________________________________________________

Street Address: ________________________________________________________

City: ____________________________, State:______, Zip(bills to): _____________

Telephone: __________________ E-mail Address: ____________________________

Credit Card Number: ________ ________ ________ ________ Expires: ____________

Security Code (CVVC Code): _____________

____ Initial here to authorize recurring payments for MSP services.
____ Initial here to authorize non-recurring payment(s) for services/products purchased.
Specific charge for: _________________________________________________________

The undersigned guarantees performance of the financial provisions of this agreement.
You agree to be billed for MSP and authorized non-MSP services.
Any card disputes must arise within 60 days of the disputed charge or they become final. You must keep your card current or replace it as needed. You may cancel this card authorization at any time.
Should legal fees be incurred to resolve any disputes the prevailing party is entitled to reimbursement.

Signature _____________________________________________Date____________

Internal Use Only
( ) Update Credit Card Info ( ) Remove from Converge
( ) Add to Card Manager ( ) Remove from n-Able
( ) Add to Recurring ( ) Reason: ______________________________________

Price: $0.00
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