Professional Life Coaching
& Business Development
	with	Darren Barr-Engstrom

Credit Card Authorization Form for Coaches

Click Here to Download a Word version of the Credit Card Authorization Form

INSERT COACHES NAME OR BUSINESS NAME Credit Card Authorization

I, ___________________________, hereby authorize INSERT COACHES NAME dba INSERT COACHES BUSINESS NAME to charge to the following credit card account in the amount shown below for monthly coaching services. This payment agreement will be in effect until services have been completed or are ended by request of the client either verbally or in writing.

CREDIT CARD INFORMATION:

Card Type: (Circle One) Visa/Mastercard

Card Number:_______________________________________

Expiration Date: _____________________________________

Name on Card:_______________________________________

Billing Address:______________________________________
Street or P.O. Box

_______________________________________
City, State Zip Code

Amount: INSERT AMOUNT CHARGED

Billing Cycle: INSERT HOW OFTEN YOU CHARGE

Cardholders Signature:__________________________________

Please complete form and fax to the following secure fax number: INSERT YOUR FAX NUMBER

Original photography and page design by Autumn Barr-Engstrom.