One Time Use or Recurring and Subsequent Sale Charges Credit Card Payments

In order for Seminole Tribe of Florida (Tribe) to accept and bill your credit card, please complete all fields below, sign, date and fax to . All information sent is strictly confidential.

Customer Name:

d.b.a.:

Customer Address:

Customer Billing Account Number:

Contact/Billing Information: (as shown on credit card)

PLEASE PRINT LEGIBLY

DATE:

ACCOUNT NUMBER:

NAME ON CARD:

TYPE OF CARD:

EXPIRATION DATE:

Credit Card Security Code (the last three digits on back of the card):

Amount:

BILLING ADDRESS (the address that the credit card statement is mailed to):

Phone (on file with credit card company):

Fax Number:

Email:

AMOUNT TO BE CHARGED:

Please Check the Appropriate Box(es):

One Time Use: I hereby authorize Tribe to charge the indicated credit card the amount indicated above. This is a one-time charge authorization . I am not authorizing the Tribe to setup my account within a recurring billing system - rather, I prefer to pay by check or money order on all future invoices I understand that if I want the Tribe to charge any balances to my credit card in the future, I will need to submit another authorization form at that time or choose the selection below. Please list what the credit card authorization is for:

Authorization:

Recurring Billing: I hereby authorize the Tribe to charge the indicated credit card on a periodic basis for the amount due under my contract with the Tribe as indicated above. This Recurring Payment Authorization/Periodic Charge shall remain in force until cancelled by me in writing. Please list what the credit card authorization is for:

I hereby authorize the Tribe to keep my signature on file and charge the indicated credit card. I agree that this is either a one time or periodic charge that will be made as indicated above. To terminate the recurring billing process, if selected, 1 must cancel in writing , otherwise the account will be manually invoiced and payment made via check, money order or wire. I understand that all account cancellations must be made in writing. I will not dispute the Tribe ‘s recurring billing with my credit card issuer so long as the amount in question was for services rendered prior to my canceling my account in the manner required . I guarantee and warrant that I am the legal cardholder for this credit card and that I am legally authorized to enter into this one time or recurring billing agreement with the Tribe. If, after a payment by credit card, I later dispute the charges, unless prohibited by law, I agree not to cancel, revoke, charge back, or dispute any previously entered charge on my credit card. If I do so, and it is later determined that the charge was properly authorized, I agree to pay all out of pocket fees and costs incurred by the Tribe as a result of the improper cancellation, revocation, charge back, or dispute.

AUTHORIZED SIGNATURE FOR CARD USER:

PRINTED NAME OF USER SIGNING:

Date:

REFERENCE (FILL IN APPROPRIATE ITEM)