Credit Card Payment
By signing this agreement, the customer and cardholder both agree to comply with and to be subject to all credit card charges specified for the amount above. Customer and cardholder hereby agree not to dispute and/or charge-back any of the charges specified above. Any violation of the terms and conditions (hence any dispute and/or charge-back of any sum specified), by the customer and/or cardholder constitutes a breach of this agreement and the company will be be entitled but not limited to the remedies specified below:
Remedies: In any case in which the customer and/or cardholder initiates any dispute/chargeback any of the monetary amounts specified on this form (partly or whole), company will be entitled to collect any and all fees and/or damages resulted from such action.
I, hereby authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization form is to be used and valid for a one-time payment use only. I certify that I am an authorized user for this account and that I will not dispute the payment with my bank/credit-card company as long as the transaction corresponds to the terms indicated in this form.
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Document Name: Credit Card Payment
Agree & Sign