EmailMe Form - PCMP - Credit Card Form

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.
Customer Name *
First Last
Business Name *
Billing Phone Number *
### - ### - ####
If you have multiple business locations, which location is this card being used for (if only one location, please enter N/A): *
I authorize Nick the Marketer, LLC to automatically bill the card listed below as specified:
Monthly Retainer Fee (this should include the credit card processing fee of 3%) *
$ Dollars
Frequency: *

How Often the Card Will Charge
*

End Billing When:
Start billing on: *
MM / DD / YYYY
Please select either the 1st or 15th of the month
Credit Card Type *
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.
Cardholder's Printed Name As It Appears on Card: *
Billing Address for Card *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Signature *
Clear
Today's Date *
MM / DD / YYYY