Licensed LP Gas Contractor · LI100065
Category V
8011 Monetary Dr B3, Riviera Beach, FL 33404
561-907-4301 · mygassolutionsplus.com

Recurring Payment Authorization

1 Customer

Customer name

Phone

Service address

City

ZIP

Email for receipts

Job / invoice number

2 The arrangement

What this payment covers

Set number of payments Ongoing until canceled

Total amount due

Paid today (down payment)

Charged

Build the schedule

Amount per payment

First payment date

Number of payments

Build it, then change any amount or date by hand — or skip the builder and add payments one at a time.

3 Getting your card on file

This form does not ask for your card number, and you should never email or text one. Sign and send the form first — the signed form is what lets us take the payment — then tell us how you'd like to hand over the card. We enter it into Square ourselves either way.

Enter my card now Type it below and it is saved when you send this form. The card boxes are Square's, our payment processor — we never see or store the number. Call me and I'll give it to you Send this form and we'll call you, usually the same business day. I'll call you with it Call the office at 561-907-4301, Monday through Saturday. We enter it into Square while you're on the line.

Name on the card

Last four digits

Both optional — they just tell the office which card you mean. Never put the full number on this form or in an email.

4 Authorization

I authorize Gas Solutions Plus to securely store my payment information and to charge the card above for the amounts and on the dates written in Section 2. I certify that I am an authorized user of this card.

I will receive a receipt for every charge. If an amount or a charge date changes, I will be notified at least thirty (30) days before the change takes effect.

If a charge is declined, I understand Gas Solutions Plus may re-attempt it and will contact me to update the card. A declined or missed payment does not cancel the balance owed.

This authorization stays in effect until the schedule above is paid in full, or, for an ongoing arrangement, until I cancel it. To stop recurring billing I will give written notice at least thirty (30) days before my next scheduled charge. Canceling recurring billing may end any service benefits tied to it.

Initial to authorize I have read and agree to the terms above.

5 Signature

Cardholder signature

Sign here

Not yet signed

Date

Today's date

Print name

Relationship to account

By signing above I agree that my electronic signature is the legal equivalent of my handwritten signature and that it authorizes the charges described in this form.

Office use only

Taken by

Date received

Entered in Square — date