Charlotte Colocation Center, LLC

Automatic Credit Card Billing Authorization Form

If you would like to enjoy the convenience of automatic billing, simply complete the Credit Card Information section below and sign the form. All requested information is required. Upon approval, we will automatically bill your credit card for the amount indicated and your total charges will appear on your monthly credit card statement. You may cancel this automatic billing authorization at any time by contacting us in writing.

 

Customer Information (To be completed by merchant)

Customer name:

 

Customer account number:

 

Phone:

 

 

 

 

 

-

 

-

 

 

Payment Information (To be completed by merchant)

I authorize Charlotte Colocation Center, LLC to automatically bill the card listed below as specified:

 

Amount: $

 

 

Frequency: Weekly Monthly Quarterly Annually (Check only one)

 

Start billing on:

 

          /          /

 

End billing when:

 

Contract expires:

 

          /          /

 

Customer provides written cancellation

 

Credit Card Information (To be completed by customer)

Charlotte Colocation Center, LLC accepts the following credit cards: Visa, MasterCard, Discover, American Express

 

Credit card type:

 

Credit card number:

 

Expires:

 

 

 

 

          /

 

Cardholder's name:

 

Cardholder's Zip code (required):

 

 

 

(as shown on credit card)

 

(from credit card billing address)

 

 

 

Customer's signature:

 

Date: