Computer Services

Tel 650.548.1010
Burlingame, CA USA - Automatic Credit Card Billing Authorization Form

Please print this form and fax it to at (801) 315-9328.

If you would like the convenience of automatic billing and take advantage of the low MRMA client rate of $55 per hour, simply complete the Credit Card Information form below and sign the form. All requested information is required. We will bill your credit card for the amount indicated and your total charges will appear on your monthly credit card statement. You may cancel this automatic billing authorization at any time by contacting us at (650) 548-1010.

Customer Information ( To be completed by ) 

Customer Name Customer account number  Phone 

MRMA Service Fee Payment Information
This is for your monthly MRMA service fee. This amount is automatically charged to your credit card on the 1st of every month.

I authorize to automatically bill the card listed below as specified:
Amount $  Monthly
Start billing: Month ________________ Day __________ Year ___________

Invoice/Work Order Payment Information
Work orders and invoices are billed to your credit card 11 days from the date of service.

I authorize to automatically bill the card listed below as specified:
Customer's signature

Credit Card Information ( To be completed by client ) 

Credit card type: Credit card number Expires

Cardholders name (as shown on card) Cardholders Zip Code (required)

Customer's signature Date | 1675 Rollins Road, Suite B2 | Burlingame | California | 94010 | 650.548.1010