EmailMe Form - Payment Authorization Form

You authorize Cool Pool People LLC to make regularly scheduled charges to your payment method on file.
Please complete the below information
Name *
First Last
Billing Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region
Phone *
### - ### - ####
Email *
Payment Options *
Debit/Credit Card
Checking/Savings Account
Cardholder Name
First Last
Credit Card
VISA
Master Card
Amex
Discover
Credit Card

Card Number

Protected in vault Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault.
Checking/Savings Account
Checking
Savings
Name
First Last
Bank Name
Account Number
Bank Routing #
Bank City/ State
Authorization *

I authorize Cool Pool People LLC to charge my account indicated below for payment of my monthly cleaning on the 1st of the month, semi-annual filter cleanings, and part replacement/repairs totaling $100 or less. I understand that I will receive email notification when charges take place.
Terms *

I understand that this authorization will remain in effect until I cancel in writing, and I agree to notify Cool Pool People LLC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date.

I certify that I am an authorized user of this credit/debit card and will not dispute the scheduled transactions with my bank or credit card Company; provided the transactions correspond to the terms indicated in this authorization form.
Signature *
Clear
Today's Date
MM / DD / YYYY
Email

You authorize Cool Pool People LLC to make regularly scheduled charges to your payment method on file.