Credit/Debit Card Recurring Payment Authorization

Cardholder's Information

First Name*

Last Name*

Email Address*

Phone Number

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Card Information

Number*

Credit/Debit Card Type*

Expiration Month*

Expiration Year*

Security Code*

Processing Date and Authorization

Charge type*

Processing start date*

Monthly amount*

Credit/Debit will be processed each month on this date until I cancel payment by emailing billing department at [email protected]. Subsequent debits will be made at any time for any amounts owed per the pertinent invoice for each month. Charges may be made a few days prior to the processing date to allow time for funds transfer from bank to bank*

Description of the transaction and or comments for billing team*

Agreement Signature
This payment authorization is to remain in full force and effect until I, (SIGNATURE BELOW) notify Blue Nile Digital Marketing of its cancellation by sending written notice to [email protected] in such time and in such manner to allow both Blue Nile Digital Marketing and the receiving financial institution a reasonable opportunity to act on it.

Type your full name as your signature of agreement

First Name*

Middle Name

Last Name*

Date*

Credit/Debit Card Recurring Payment Authorization

Company

Our Solutions

Contact Info