Automatic Billing Authorization

If you would like to enjoy the convenience of automatic billing, simply complete the Credit Card Information section below and sign the form. All requested information is required. Upon approval, we will automatically bill your credit card for the amount indicated and your total charges will appear on your monthly credit card statement. You may cancel this automatic billing authorization at any time by contacting us.

Client Billing Authorization

Customer Information
Client Name*
First Last
Company Name*
Phone*
Payment Information
I authorize Audiology Ignite to automatically bill the card or charge the ACH account listed below as specified:
Amount:*
Start Billing On:*
MM slash DD slash YYYY
Credit Card Information
Credit Card Type:
Credit Card Number:
Expiration Date:
Cardholder's Name:
Zip Code
CVV
ACH Billing Information
I authorize Audiology Ignite to electronically debit my bank account according to the terms outlined below. I acknowledge that electronic debits against my account must Comply with United States law.
Routing Number
Account Number
Type of Account
- Checking
- Savings
- Consumer
- Business
Approval
Type Your Name To Act As a Signature*
Todays Date*
MM slash DD slash YYYY

Client Billing Authorization

Customer Information

Payment Information

Credit Card Information

ACH Billing Information

Approval