Please provide accurate identification information to ensure compliance with international card scheme regulations and anti-fraud measures.
Entity Type
Individual
Business Entity
Non-profit Organization
Government Agency
Business Entity Details (provide all required information)
Non-profit Organization Details
Government Agency Details
Primary Cardholder Full Legal Name
Customer Account ID with Merchant
Primary Email Address
Primary Phone Number (with country code)
Billing Address Line 1
Billing Address Line 2
City
State / Province / Region
Postal / ZIP Code
Country
Enter your card information securely. All data is encrypted and tokenized upon submission in compliance with PCI DSS global security standards. CVV/CVC is required for verification but never stored.
Card Type
Visa
Mastercard
American Express
Discover
JCB
UnionPay
Diners Club
Other
Card ID
Cardholder Name (exactly as printed on card)
Expiry Date
CVV / CVC Security Code
Is the billing address for this card identical to the address provided above?
Provide the complete billing address registered with your card issuer
Street Address
Street Address Line 2
City
State / Province / Region
Postal / ZIP Code
Country
Provide the complete billing address registered with your card issuer
Identify the merchant and specific service agreement this authorization relates to for accurate transaction processing and record matching.
Merchant Legal Business Name
Detailed Description of Services or Products
Merchant Invoice Number or Agreement Reference
Original Service Agreement Date
Define the precise scope and limitations of this authorization to maintain financial control and prevent unauthorized charges.
Authorization Type
One-time Payment Only
Recurring Billing Mandate
One-time Payment with Separate Recurring Setup
This authorization is strictly limited to a single transaction only. No future recurring charges will be processed under this mandate.
This establishes an ongoing payment mandate. You must complete the 'Recurring Billing Mandate Details' section below.
This authorizes both an immediate one-time payment AND establishes a separate recurring mandate. Complete both transaction details and recurring sections.
Amount Type
Fixed Amount (same for every transaction)
Variable Amount (may differ each time)
Maximum Authorized Amount per Transaction
Overall Spending Limit (cumulative, optional)
Currency Code (ISO 4217 standard)
Complete this section to establish a recurring payment mandate. Skip if one-time payment only. All fields are required for recurring setups.
Billing Frequency
Weekly
Bi-weekly (every 2 weeks)
Monthly
Bi-monthly
Quarterly
Semi-annually
Annually
Custom Interval
Specify Custom Interval
Day of Month for Billing (1-31, enter 31 for last day of month)
First Billing Date
Mandate Duration
Ongoing Until Cancelled
Fixed Number of Payments
Until Specific End Date
Until Event/Occurrence
Total Number of Payments Authorized
Final Billing Date
Describe the Event/Occurrence that Ends Billing
Is there a trial or introductory period?
Trial Period Amount (enter 0.00 if free trial)
Trial Period Duration (in days)
Should the first payment be prorated if the start date is mid-billing-cycle?
Provide detailed transaction information for accurate invoice matching and accounting reconciliation.
Itemized Transaction Details
Item Description | Quantity | Unit Price | Tax Rate % | Line Total | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | Enterprise SaaS License - Tier 3 | 1 | $299.99 | 10 | $329.99 | |
2 | Implementation & Onboarding | 1 | $149.99 | 10 | $164.99 | |
3 | Premium 24/7 Support | 12 | $49.99 | 10 | $659.87 | |
4 | $0.00 | |||||
5 | $0.00 | |||||
6 | $0.00 | |||||
7 | $0.00 | |||||
8 | $0.00 | |||||
9 | $0.00 | |||||
10 | $0.00 |
Purchase Order Number
Invoice Number
Total Amount to be Authorized
Total Tax Amount
Enhanced security measures protect against unauthorized use. Complete all applicable verification fields.
Is this card enrolled in 3D Secure (Verified by Visa, Mastercard SecureCode, Amex SafeKey)?
3D Secure Authentication Transaction ID or Code
May we securely store a tokenized version of this card for future transactions?
May we send OTP (One-Time Password) for transactions above your specified threshold?
OTP Threshold Amount
Preferred OTP Delivery Method
SMS
Authenticator App
Voice Call
I consent to device fingerprinting and IP address logging for fraud prevention
IP Address of Submitting Device (auto-captured)
Configure your notification preferences to stay informed about all payment activities.
Email for Payment Receipts (if different from primary email)
Mobile Phone for SMS Alerts (if different from primary)
Select all notification types you wish to receive
Payment Successful
Payment Failed
Upcoming Payment Reminder (3 days before)
Payment Method Expiry Alert (30 days before)
Spending Limit Approaching
Mandate Cancelled Confirmation
Suspicious Activity Alert
Statement Descriptor Preference (appears on your card statement)
Full Merchant Legal Name
Short Merchant Code (6-8 characters)
Custom Descriptor
Custom Descriptor (max 22 characters, no special symbols)
You must acknowledge and accept all terms to proceed. These terms are governed by international card scheme rules (Visa, Mastercard, Amex) and universal commercial law principles.
I understand this is a legally binding payment authorization enforceable under applicable commercial law
I agree to the merchant's terms of service, privacy policy, and data handling practices
I understand the cancellation policy requires minimum 7 business days notice before next scheduled billing date
I acknowledge the refund policy: no refunds after 30 days from payment date; partial refunds before 30 days subject to administrative fees
I consent to PCI DSS compliant storage and processing of my card information by the merchant's payment processor
I understand I can revoke this authorization by submitting written notice to the merchant's official contact
I acknowledge that variable recurring amounts may differ between billing cycles but will never exceed the maximum authorized per transaction
Do you require a certified copy of the full terms and conditions document for your records?
Delivery Method for Terms Document
Email PDF
Postal Mail
Secure Download Link
Not Required
Provide a backup payment method to prevent service interruption if the primary card is declined, expired, or reported lost.
Would you like to register a backup payment method?
Please complete the backup payment fields below. All backup card data will be tokenized and stored with the same security as your primary method.
Backup Card ID
Backup Cardholder Name
Backup Card Expiry (MM/YY)
Backup CVV/CVC
Backup Payment Usage Policy
Use only if primary payment fails
Use only if primary card expired
Use for all transactions (alternate monthly)
Use if primary exceeds limit
Provide any special instructions or supporting documents required for processing this authorization.
Special Payment Instructions or Internal Allocation Notes
Upload Supporting Documents (purchase order, invoice, approval memo, tax exemption certificate)
Merchant Internal Reference Number
Your electronic signature legally binds you to this authorization. All data is captured with timestamp and device identifiers for forensic verification.
I consent to using electronic signature and acknowledge it has the same legal effect as a handwritten signature under applicable law
You must consent to electronic signature to complete this digital authorization. Please contact the merchant directly for paper-based alternatives.
Signature of Cardholder or Authorized Representative
Authorization Date
To configure an element, select it on the form.