Bauer & Bauer, LLC One-Time ACH/Credit Card Payment Authorization Form
Client Information
Name______
Address______
______Bauer & Bauer, LLC
City______939 Keystone Way
State______Zip ______Carmel, IN 46032
Email______317-581-9353
Please select only one payment option below:
___ Bank Account Information___ Checking ___ Savings
______
Bank Name
______
Bank Routing Number
______
Bank Account Number / ___ Credit Card Information
___ MasterCard ___ VISA ___ American Express ___ Discover
______
Name on Credit Card
______
Credit Card Number
______*Customer address is same as credit
Expiration Date (mm/yy) card billing address ___Yes ___No
*If the address is not the same, please provide credit card billing address: ______
______
Invoice Number =______
Transaction Date = ______
Total Payment Amount =______
Authorization Agreement
I hereby authorize Bauer & Bauer, LLC (Bauer) to process a one-timeACH debit or credit card charge from the indicated bank account/credit card for services rendered by Bauer. This is valid for one-time use only. If Bauer is unable to process my payment I will be responsible for an alternative method of payment and any associated processing fees. I understand that all account cancellations must be made in writing according to the requirements of the Bauer Terms of Professional Services Agreement, which I have read and understand. I will not dispute Bauer’s billing with my credit card issuer so long as the amount in question was for service rendered prior to my canceling my account in a manner required by the Terms of Professional Service Agreement.
For ACH debits to my checking/savings account, I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This ACH agreement shall not alter, enlarge or diminish the existing rights and obligations of the parties under your Terms of Professional Service Agreement.
I agree that if I have any problems or questions regarding my Bauer service, I will contact Bauer for assistance, using the contact information located on their website at I agree that I will not dispute any charges from Bauer unless I have already attempted to rectify the situation directly with Bauer and those attempts have failed.
I authorize Bauer and their payment gateway to run an address verification search. This verification process is a security measure to protect me, the client, from illegal fraud against my credit card. I guarantee and warrant that I am the legal cardholder for this credit card, and that I am legally authorized to enter into this one-timepayment agreement with Bauer.
BY SIGNING AND DATING BELOW, I CONSENT TO THE TERMS OF THE AUTHORIZATION AGREEMENT FOR ACH DEBITS AND CREDIT CARD CHARGES ABOVE.
______
Authorized SignatureDate
email, or mail this form to the following: ; 939 Keystone Way