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Credit Card or ACH Authorization Form
Credit Card or ACH Authorization Form
Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.
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Your Information
Company Name
*
Your Name
*
Your Email Address
*
Your Phone
*
Card or ACH Information
Billing Type
Credit Card
ACH
Account Holder Type
*
Business
Individual
Account Holder Name
*
Routing Number
*
Account Number
*
Confirm Account Number
*
Card Type
*
MasterCard
VISA
Discover
American Express
Cardholder Name (as show on card)
*
Card Number
*
Expiration Date (mm/yy)
*
Cardholder ZIP Code (from credit card billing address)
*
Security Code
*
Consent
*
I authorize
I authorize the purchase of service from Fixed Ops Digital. I agree to pay for purchases made under this agreement and to indemnify and hold Fixed Ops Digital harmless against any liability pursuant to this authorization.
Electronic Signature
*
Date
*
MM slash DD slash YYYY
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