Authorization to Charge Credit Card for Services

By filling this form, you hereby give your permission and authorization to allow Itzik Rapaport to charge your credit card on a recurring basis as a method of payment for his coaching services. If other payment has been made or agreed upon, credit card will not be charged.

First Name

Last Name

Cardholder Name

Card Number

Card Type

VISA

Mastercard

Discover

Others

Expiration Date

CVV Number

Billing Zip Code

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I understand this this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.

Authorization to Charge Credit Card for Services

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