Credit Card Authorization

Secure Payment Form

Credit Card Authorization Form

Authorize A-Team Total Care to charge your credit card for services.

Secure Payment Processing

Your payment information is encrypted and processed securely. We never store your complete credit card information.

Cardholder Information

Cardholder Name (as it appears on card) *

Billing Address *

City *

State *

ZIP Code *

Phone Number *

Email Address *

Payment Information

Card Type *

Card Number *

Expiration Month *

Expiration Year *

CVV *

Authorization Details

Authorization Type *

One-time payment

Single charge for specific service

Recurring payments

Regular scheduled payments

Automatic payment

Charge card automatically when services are completed

Authorized Amount

Service Description *

Terms and Agreement

Authorization Terms:

I authorize A-Team Total Care, LLC to charge my credit card for the services described above
I understand that this authorization will remain in effect until I cancel it in writing
I agree to notify A-Team Total Care of any changes to my account information
I understand that cancellation must be received at least 3 business days before the next scheduled payment
I acknowledge that A-Team Total Care will provide advance notice of any charges

I agree to the terms above and authorize A-Team Total Care, LLC to charge my credit card as described. *

Signature Date *

Electronic Signature Notice: By submitting this form, you are providing an electronic signature that has the same legal effect as a handwritten signature.