Credit Card (ACH) Authorization Forms (4)

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Updated September 03, 2022

A credit card authorization form allows a third party to make a payment by using a person’s written consent and credit card information. This can either be for a 1-time charge or recurring (weekly, monthly, etc). This is a common procedure when an individual authorizes a subscription that renews on a monthly basis (such as gym memberships, monthly rent, etc.).


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Credit Card Details

Card Type: Visa MasterCard American Express Discover [OTHER]
Cardholder Name: [FULL NAME]
Credit Card Number: [XXXX-XXXX-XXXX-XXXX]
Expiration Date: [MM/YYYY]
Billing Zip Code: [ZIP CODE]


I, the undersigned cardholder, authorize the merchant known as [MERCHANT’S NAME] to charge my credit card for purchases related to goods and services. I agree that my information may be saved by the merchant for future payments and understand that this can be revoked at any time with request.

Cardholder’s Signature: ________________________ Date: _______________


Table of Contents

Main Types (4)

1-Time Credit Card Authorization – A general form for a charge that will be made for a single payment on a credit card.

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Recurring Credit Card Authorization – The act of using an individual’s or business’s credit card for a charge that will repeat in a timely period (Usually on a monthly basis).

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1-Time ACH Authorization – Make a one (1) time payment via bank account (checking or savings) by providing the Account and Routing numbers.

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Recurring ACH Authorization – To provide bank account information for the use of a payee to process payments on a periodic basis.

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Other Types (2)

Airline Credit Card Authorization – For any person seeking to pay an airline ticket via paper form.

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Hotel Credit Card Authorization – For the use of a guest that is going to be using a third (3rd) party’s credit card in order to stay at a hotel.

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What is a Credit Card Authorization Form?

A credit card authorization form serves 2 primary purposes that play a large and important role for businesses and merchants. First, it gives a business the authority to charge a credit card without the buyer being physically present. Second, it prevents unwanted and fraudulent chargebacks that can hurt the relationship between a business and a merchant processor. If a business is getting too many chargebacks, its merchant provider may eventually cease to do business with them.

How to Accept a Payment

Use the following instructions to charge a credit card or bank account by obtaining the customer’s credentials via a paper form.

Step 1 – Point of Sale

man processing customer's information on laptop

When a buyer and seller have come to terms for the purchase of goods or services, the consent may begin to be filled in. The following information will be required by the processor:

Credit/Debit Card

  • Cardholders Name
  • 16 Digit Number
  • Expiration Date
  • Billing Address

Bank Account (ACH)

  • Account Holder’s Name
  • Address (of the Account Holder)
  • Routing Number
  • Account Number

Step 2 – One-Time Charge or Recurring

person writing check next to one-time charge on credit card ach payment authorization

Enter whether the account will be charged on a one-time payment or will it be continuing on a recurring basis.

Step 3 – Cardholder Signs

cardholder signing authorization form

The cardholder must sign the authorization form. If being used for a hotel room authorization the form may be signed by the cardholder and faxed to the lodging establishment.

Chargebacks and Disputes

Due to how easy it is to call a bank and report a false or fraudulent charge, there needs to be a way for merchants to minimize losses in order to protect their business. Even though businesses can dispute a chargeback, it still has a negative effect. Most businesses are allowed a dispute range of no more than 1%-3%. If a business has a dispute ratio higher than the allowed rate, their payment processor will likely suspect their business to be practicing shady ethics. And to keep the number of disputes down, many businesses will take the loss and refund the customer which can be highly unfair to the business. Any business that sees high or unfair disputes, should adopt a credit card authorization form for customers to sign anytime they can.

Authorization Hold ($1)

A credit card authorization hold works a bit differently than an authorization form in that it temporarily draws funds from the customer’s account as a pending transaction and ensures that the customer has the funds in their account to complete the purchase. The authorization hold can range from $1 dollar all the way to the full amount depending on the situation.

This is a common practice that gas stations and hotels widely use to prevent fraud. With websites such as, they allow customers to reserve a hotel with no money down but after a specified date, the customer can no longer cancel without being charged for partial payment or the entire amount which is also another example of an authorization hold.

How to Fill-out

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1 – Open And Download The Authorization Template On This Page

Use the PDF, Word, or ODT button corresponding to the preview image on this page to open this document then save it to your machine. Make sure to have your account information handy when filling out this form as this will need to be presented accurately.

2 – Choose How Frequently This Payment Should Occur

This paperwork will handle the task of proving your intent to allow another person to use one of your accounts to pay a bill. This approval should be given with a clear distinction of how often this payment may occur. If the payment you are authorizing is a recurring payment, one that your account should pay automatically every billing cycle, then place a mark in the check box labeled “Recurring Charge.” If the payment you are authorizing should only be made once, and by virtue of this form, then check the box corresponding to “One (1) Time Charge.” Keep in mind this will mean that after this payment is made, the approved party will be unable to submit the same payment at any point in the future using this authorization.

3 – Furnish Your Choice With The Requested Information

Now that we have solidified how often the authorized payment is allowed, we will need to disclose some basic facts regarding the parties and amounts involved. Please note, that while the same basic information is requested in each of the choices, you should only furnish information to the paragraph attached to the check box you selected. Thus, begin by locating the check box you marked, then enter your First, Middle, and Last Name on the first blank space (labeled “Full Name”) in that statement. Next, on the space labeled “Merchant’s Name,” enter the Legal Name of the party that you will make the defined payment to. You must authorize a definitive sum of money for payment. Produce this Dollar Value on the blank line labeled “(Amount $)”In addition to an authorized Dollar Amount, you must indicate when this payment should be made from your account. If you have selected “Recurring Charge,” then you must use the blank spaces labeled “Day” and “Week, Month, Etc.” to define precisely when you authorize the third party to pay the named Merchant the defined Amount. For instance, you can authorize the third party’s use on “Tuesday” every “Week” or on the “15th” of every “Month.” If you have selected “One (1) Time Charge,” then enter the Calendar Date you expect the third party to pay this charge on the blank line labeled “Date.”Give a detail of what the payment is being used for on the line labeled “Description Of Goods/Services.”


4 – Produce The Billing Information Required By The Authorization Process

The section labeled “Billing Information” will seek some basic information regarding the Account Holder. As the Account Holder, you must sign this document. We will begin with the line labeled “Billing Address.” Use this space to report the Account Holder’s Building Number, Street Name/Number, and Unit Number listed on the account being used to pay the above-named Merchant.   Use the blank space below the Street Address you just entered to record the City, State, and Zip Code listed associated with Account Holder’s Billing Address on the space labeled “City, State, Zip.” The Account Holder’s Phone Number and E-mail Address should both be recorded in this area. Use the blank spaces labeled “Phone #” and “Email” to present this information.

5 – Detail The Method Of Payment Being Authorized

The final section requiring information is composed of two boxes: “Bank (ACH)” and “Credit Card.” Only one of these boxes should be filled out with information. Determine which account you wish used to make the payment then fill out the appropriate area.

If you intend on approving the third party’s use of your “Checking” or Savings” account to make this payment, then you must mark the appropriate check box in the “Bank (ACH)” area. That is, place a mark in the check box labeled “Checking” or the check box labeled “Savings.”  You will also need to supply the Full Name of the Account Holder on the blank line labeled “Name On Account.” Next, present the Name of the Bank where your account is held on the “Bank Name” line.  Finally, document the “Account Number” and “Routing Number” the bank assigned to the account you are authorizing payment from utilizing the next two blank lines in this box. If you intend to authorize a third party’s use of your “Credit Card,” then mark the check box labeled “Visa,” “Mastercard,” “Amex,” or “Discover” from the choices presented in the area on the right. To approve a third party’s use of your Credit Card for this payment, supply your Name on the blank space labeled “Card Holder Name.” Next, report the Credit Card Number you wish the funds to be drawn from on the blank space labeled “Account Number.”  Finally, transcribe the Expiration Date on your Credit Card to the lines labeled “Exp. Date” along with the three-digit CVV code associated with your credit card (usually located on the signature area on the back of your Credit Card) on the blank line labeled “CVV.”

6 – Demonstrate Your Intent To Authorize The Defined Payment Information

In order to provide proof of your approval, the Acknowledgement Statement presented should be completed. Locate the blank space that follows the dollar sign in the statement beginning with the words “I Understand That This Authorization…” Record the penalty amount the Account Holder must pay each time the charge is rejected due to insufficient funds on this space. If this information is not readily available then you should contact the Merchant to satisfy this statement. You, as the Account Holder, must sign your Full Name on the blank space labeled “Bank Account/Cardholder’s Signature” Finally, enter the Calendar Date when you signed this form on the line labeled “Date.”