Credit Card Payment Authorization Form

This is a credit card agreement drawn up by Tinypint LLC for their clients.

Credit Card Payment Authorization Form

By filling out the form below, you are authorizing Company Name to bill your credit card for payments toward your account. You understand that some payments, such as monthly services like hosting or agreed-upon milestones, will be billed automatically. Monthly recurring agreements are sent out on the twenty-third of each month prior to the service term, with payment automatically collect first of the month, or at whatever predetermined schedule is agreed upon.

Please complete the information below:

I, Client Name, an authorized representative of Client Company Name, authorize Tinypint, LLC to charge my credit card account indicated below for the purpose of obtaining payment for invoices on my account.


Billing Address:

Billing Address

City  State , Zip/Postal


Credit Card Information

Cardholder Name: (as it appears on the card)

Card Type: (Mastercard, Visa, AMEX or Discover)

Card Number: (spaces or dashes are allowed)   CVV2: (on back of your card or front of AMEX)  Exp. Date:  MM/YY 


SIGNATURE __________________________________              DATE __________________

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.


Document Discussion

If this site holds itself out as making the law more accessible and harvesting forms from lawyers, then it seems kind of irresponsible to circulate this type of form without advising laypeople about laws in states like Nevada that credit card information needs to be encrypted.

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