"*" indicates required fields
The following fees are charged by the credit card gateway service:
I hereby authorize Card Concepts Inc. (hereafter "CCI") and the credit card gateway service to initiate debit entries for the sums detailed above and initiate (if necessary) credit entries and adjustments for any debit entries in error to the account indicated in bank information named above, to debit and/or credit the same to such account.
This authority is to remain in full force and effect until CCI has received written notification from customer of said authority's termination and in such manner as to afford CCI a reasonable opportunity to act.
To agree to all terms above and contained herein, please enter your full name below and sign with your mouse/finger.