Recurring Billing Authorization Please fill out and submit the form below to authorize Eleven Tree Media to perform automatic/recurring billing. Once this info is received it will be applied to all recurring billing moving forward. Recurring Billing Authorization Company Name*Email* Website* Card Type?*–Please Select–VisaMaster CardDiscoverAmerican ExpressCardholder Name* First Last Card Number*Card Expiration Date*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*20252026202720282029203020312032CVC/Security Code*Billing Zip Code*Authorization* Authorize & Accept I/We understand that this authorization will remain in effect until I/We cancel it in writing, and I/We agree to notify Eleven Tree Media in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I acknowledge that the origination of Credit Card transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this Credit Card and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorization form. I/We understand recurring billing happens on the following dates: March 1st – March 15th June 1st – June 15th September 1st – September 15th December 1st – December 15th *Please Note: This is for recurring billing ONLY. Your card will not be run for other projects you are doing with us.Specific Date*If you have a preference of a specific date in the timeframe for the billing periods please select what day you would like the transaction to run. Otherwise we will run it in the timeframes above.Date* MM slash DD slash YYYY Cardholder's Signature* Δ
