Recurring Payment Authorization Form

If you would like the convenience of automatic recurring 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/Company

Contact Name

First Name

Last Name

Participant Name

Name of Participating Party (if different from above contact name)

Email

Please select your preferred day

Authorization

I authorize Unlock Potential to automatically bill the card listed below for 4 payments of $375.

Yes

No

Account Number

Cardholder name as it appears on the credit card

First Name

Last Name

Card Type

MasterCard

VISA

Discover

AMEX

Other

Card Number

Cardholder ZIP Code

From credit card billing address

Expires

Date of credit card expiration

MM

DD

YYYY

Notify me via email when my credit card is charged.

Please make sure the email above is correct.

Yes

No need, thanks.

Electronic Signature