Forms, consent and waiversForm
Credit card authorization form template
Get a customer's written permission to charge their card for a one-off or recurring amount: what will be charged and when, how to cancel, and how card details are kept safe.
Opens in the Salsox editor with 7 signing fields already placed for Business and Cardholder. Add their emails and send. The free plan sends 3 documents a month.
Who signs
- Business (you)
- Cardholder
Preview
Credit Card Authorization
Business: Summit Fitness Studio Cardholder: Rachel Thompson
1. Card
| Detail | Entry |
|---|---|
| Card type | |
| Last four digits | |
| Expiry month and year | |
| Billing postcode or ZIP code |
The full card number is entered through the business's secure payment page and is not written on this form.
2. Charges authorized
| Detail | Entry |
|---|---|
| What the charge is for | monthly membership, unlimited classes |
| Amount | USD 89.00 |
| When | on the 1st of each month, starting 1 November 2026, until cancelled |
3. Authorization
I authorize Summit Fitness Studio to charge the card above for the amount and on the schedule shown. I confirm I am the cardholder, or am authorized to use the card. Recurring charges continue until I cancel in writing at least 7 days before the next charge date. A change to the amount needs a new authorization.
4. Questions and disputes
I will contact the business first about any charge I do not recognize. I keep the rights my card issuer gives me.
5. How card data is kept
The business will not store the full card number or security code, and will keep this form securely, with access limited to staff who need it.
Cardholder initials: Initials · Cardholder
Signatures
Cardholder: Signature · Cardholder Date: Date · Cardholder Name: Name · Cardholder
For the business: Signature · Business Date: Date · Business Name: Name · Business
These templates are general starting points, not legal advice. Laws differ between countries and states: check that a template suits your situation, or ask a lawyer, before you rely on it.
About the Credit card authorization form template
A credit card authorization form records a customer's permission for a business to charge their card, either once or on a schedule. It is used where the customer is not present at the time of the charge: memberships, retainers, deposits, and phone or email orders.
This form states the amount, what it is for and when it will be charged, and how the cardholder can cancel. A signed authorization is useful evidence if the cardholder later disputes a charge, though card network rules decide every chargeback.
Card data is sensitive. Do not collect the full card number or security code on a form that is emailed or stored. The safest approach is to take the card through your payment provider's secure page and use this form for the authorization only; the template asks for the last four digits, not the full number, for that reason.
- Signers
- 2
- Signing fields placed
- 7
- Details to fill in
- 6
How to use this template
Open it in Salsox
Choose Use this template. Sign up free if you have no account; the template opens straight after.
Fill in the details
Type your details into each blank, or start from the sample to see how it reads. Save it as your own template to reuse it.
Add signers and send
The editor already has every signature, date and initials field in place. Add each signer's email and send; they sign on their phone, and everyone gets the sealed copy with its audit trail.
Used in
Questions
Should the form collect the full card number?
Not on a document that is emailed or stored. Card industry rules forbid keeping the security code at all. Take card details through your payment provider and record only the last four digits here.
Does a signed form prevent chargebacks?
No, but it is strong evidence that the cardholder agreed to the charge, which helps when responding to a dispute.
How does the cardholder cancel recurring charges?
In writing, before the notice period in section 3. The business must stop charging once the notice takes effect.
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Send it for signature in minutes
Start from this template in Salsox: fill in the blanks, add your signers and send by email, WhatsApp or SMS. Signers sign one field at a time on their phone, and you can collect a payment in the same step.