Authorization Monthly Withdrawals-Credit Card

Personal Letter


RE: __(Name)__ - __(Reference/Policy)__ __(#)__

I do hereby give authorization to __(name of organization)__ to automatically withdraw monthly __(payments/premiums)__ from my credit card for __(Briefly describe what the payments are for)__, as indicated below:


Name: ______________________________________________________________

First Middle Last


Street/Box # City State/Province Zip/Postal Code

Phone Number: ________________________

VISA ___ MasterCard ___ AMEX ___ Discover ___

CARD # ______________________________________________________

Expiry Date: ____/_____

Mo. Year

Monthly Withdrawal Amount: $____________

Authorized Signature: X_________________________ Date: ________________


I trust you will find all to be in order and thank you for your attention to this matter.

Yours truly,