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Automatic Credit Card Billing Authorization Form

Upon your approval, we will automatically bill your credit card for the appropriate amount and the total charges will appear on your monthly credit card statement. You may cancel this automatic billing authorization at any time by contacting us. By filling out and submitting this form you agree to the below terms and conditions. 

Terms and Conditions.

  • I authorize Back40 Design, Inc. to automatically bill my credit card for services provided to me (or my company) by Back40 Design.
  • I understand that my credit card will be billed automatically for current charges, or recurring billing cycles.
  • I understand that the charge amount will be agreed upon by myself or a representative of my company according to contractual status with Back40 Design, Inc.
  • I understand that on-time payment remains my responsibility. Thus, I acknowledge that it is my obligation to make payment on any declined transactions immediately upon being notified.
  • I understand that I may cancel this automatic credit card billing agreement at any time by contacting the billing department at Back40 Design, Inc. with this request.

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