Cardholder Information
Full Name on Card: [[Cardholder Full Name as it appears on card]]
Billing Address: [[Full Billing Address, City, State ZIP]] (must match card issuer records)
Phone: [[Cardholder Phone]]
Email: [[Cardholder Email]]
Payment Card Details (To Be Completed by Cardholder)
Card Type: [[Visa / MasterCard / American Express / Discover / Other]]
Card Number (last four digits only for security): ** ** [[Last 4 Digits]]
(Full card number, expiration, and CVV will be captured securely via [[merchant's secure payment processor / encrypted form / phone / other PCI-compliant method]] and will not be stored in this document.)
Expiration Date: [[MM / YY]]
CVV / Security Code: [[To be provided securely, not written here]]
Authorization Details
I, the undersigned cardholder, hereby authorize [[Merchant / Business Name]] (the "Merchant") to charge my credit or debit card for the following:
Transaction Type: [[One-time charge / Recurring charge / Installment]]
Amount(s):
- Initial / One-time Amount: $[[Amount]]
- Recurring Amount (if applicable): $[[Amount]] per [[month / week / billing cycle]]
- Start Date for Recurring: [[Date]]
- End Date or Number of Payments: [[Date or "until canceled" or "X payments"]]
Purpose / Description of Charges: [[e.g., "Payment for [[product/service description]]", "Deposit for event on [[date]]", "Monthly subscription for [[service]]"]]
Billing Frequency (if recurring): [[Monthly on the [[day]] of each month / Weekly / As services are rendered]]
Cancellation and Modification
I understand that:
- For one-time charges, this authorization is limited to the amount(s) stated above.
- For recurring charges, I may cancel this authorization at any time by providing written notice to the Merchant at the address or email above (or through any online account portal provided), allowing a reasonable processing period (typically [[5-10 business days]]). Cancellation will not affect charges already processed.
- The Merchant may modify recurring amounts only with my prior written or electronic consent, or as otherwise disclosed in the Merchant's terms of service.
PCI-DSS and Data Handling
The Merchant represents that it (or its payment processor) complies with the Payment Card Industry Data Security Standard (PCI-DSS) for the secure handling, storage, and transmission of cardholder data. Full card details are not retained in this paper form. Any electronic capture is processed through a PCI-compliant gateway.
I acknowledge that I have been informed of the Merchant's privacy policy and data handling practices.
Authorization and Signature
I certify that I am the authorized cardholder or have the legal authority to use the card described above for the charges authorized herein. I agree to pay the charges in accordance with the card issuer's agreement.
I understand that this authorization is valid for the transaction(s) described and that the Merchant will retain this form (or a secure electronic record) for its records and for dispute resolution purposes.
Cardholder Signature: ______________________________ Date: ___________
Printed Name: [[Cardholder Full Name]]
For Merchant Use Only (Internal)
Authorization Obtained By: ______________________________ Date: ___________
Method: [[In-person / Phone / Online form / Mailed form]]
Transaction ID / Confirmation (if applicable): [[Reference Number]]
Notes: [[Any special instructions or exceptions]]
Template - not professional (legal/financial/medical) advice. This is a sample credit card authorization form template. Use of this form does not guarantee compliance with PCI-DSS, card network rules, or applicable consumer protection or electronic payment laws (e.g., EFTA, state laws on recurring billing disclosures and cancellations). Merchants should use PCI-compliant payment processors for card data capture and storage. Recurring billing disclosures and cancellation rights vary by jurisdiction and card brand. Consult qualified counsel and your payment processor for compliant forms and procedures. As of 2026.
Primary Sources / Notes (as of 2026-06):
- PCI Security Standards Council requirements (PCI-DSS)
- Card brand operating rules (Visa, Mastercard, Amex, Discover) on authorization, recurring billing, and cancellation
- Federal and state laws on unfair or deceptive acts, automatic renewal, and consumer disclosures (e.g., state auto-renewal statutes)
Merchants should maintain records in accordance with applicable retention and security requirements.
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Additional Cardholder Protections and Disclosures (Optional but Recommended)
Dispute Rights. If I believe a charge was unauthorized or incorrect, I agree to first contact the Merchant at the phone or email above to attempt resolution before initiating a chargeback with my card issuer. The Merchant will investigate and respond within [[ten (10)]] business days.
Receipts. The Merchant will provide a receipt or confirmation for each charge processed under this authorization via [[email / mail / account portal]].
Updated Card Information. If the card expires, is replaced, or account information changes, I agree to provide updated information promptly to avoid interruption of recurring services.
International / Currency. If any charge involves currency conversion, the conversion rate and any fees will be disclosed at the time of processing or as required by the card network.
Retention of Form. This signed authorization form (or secure electronic equivalent) will be retained by the Merchant for a period consistent with PCI-DSS, tax, and legal requirements (typically at least [[three (3) to seven (7)]] years) and then securely destroyed.
Merchant Internal Compliance Notes
- Verify that the billing address matches the card issuer's records (AVS check recommended).
- Obtain CVV for card-not-present transactions where permitted.
- Do not store full PAN, CVV, or magnetic stripe data after authorization unless in a PCI-compliant environment.
- For recurring transactions, provide clear disclosure of the recurring nature, amount, and cancellation method at the time of initial authorization.
- Comply with all applicable state automatic renewal and continuous service laws (e.g., advance notice of renewal price increases or term changes).
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Sample Recurring Billing Disclosure Language (For Use at Point of Sale)
"By signing this authorization, you agree that [[Merchant]] may charge your card $[[Amount]] on a [[monthly]] basis beginning [[Date]], until you cancel. You may cancel at any time by contacting us at [[phone/email]] or through your account settings. You will receive confirmation of cancellation. Charges will appear on your statement as [[descriptor]]."
Attach or provide this disclosure to the cardholder at the time of authorization.
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Acknowledgment of Receipt of Copy
The cardholder acknowledges receipt of a completed copy of this authorization form.
Cardholder Initials: _____ Date: ___________
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Frequently Asked Questions (For Cardholder Reference)
Q: Can the Merchant charge more than authorized?
A: No. Charges are limited to the amounts and schedule stated in this authorization unless you provide additional written or electronic consent.
Q: What if my card is lost or stolen?
A: Notify your card issuer immediately to block the card. Also notify the Merchant so they can update payment information or pause recurring charges.
Q: How long does the Merchant keep this form?
A: In accordance with PCI-DSS and applicable record retention laws, typically several years after the last transaction or termination of the relationship.
Q: Can I get a copy later?
A: Yes. Contact the Merchant at the information above to request a copy of your authorization record.
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Merchant Contact for Questions or Disputes
For questions about charges, to update payment information, or to dispute a charge processed under this authorization, contact: [[Merchant Customer Service Phone / Email / Portal URL]].
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