I (We) hereby authorize Premium Merchant Funding 18 LLC (Company) to initiate entries to my (our) credit card accounts at the financial institution listed below, and, if necessary, initiate adjustments for any transactions credited/debited in error.
Credit Card Number *
Exp. Date *exp. month010203040506070809101112
exp. year2025202620272028202920302031203220332034203520362037203820392040
CVV *
We offer 2 payment options:
-- select one --One-Time PaymentFixed Recurring Payments
Authorization for a single, specified payment.
Please make this charge on: *
for the amount of $ *
Authorization for recurring payments on a daily/weekly/monthly basis, specifying the amount of each debit, until the total balance has been satisfied.
Please start the charges on: *
Select frequency: *dailyweeklymonthly
Business Name * Business ZIP Code * Your Signature *
Today's Date *
If you should need to notify us of your intent to cancel and/or revoke this authorization you must contact us 3 days prior to the questioned debit being initiated. Please call 516-696-7863 or email [email protected], Monday - Friday from 9:00am to 5:00pm.