Payment Authorization Form | Georgia

Name(Required)

First Last

Email(Required)

Phone(Required)

What is the name of your location we are servicing?

Payment Authorization

Important Billing Notice

Please note that while we require payment information to be submitted during onboarding, your card will not be charged until after your service is completed.

This ensures you are only billed once the work has been fully performed and verified. If you have any questions, feel free to contact our Client Services Team.

Select your preferred method of payment:(Required)

ACH or Bank Transfer (0% Fee)

Credit / Debit Card (3% Fee)

Check ($39.99 Paper Handling Fee)

Account Type:(Required)

Checking

Savings

Name on Account(Required)

Routing Number(Required)

Account Number(Required)

Name of Financial Institution(Required)

Phone Number(Required)

Please type Full Name for Signature(Required)

Card Holder Name(Required)

Cred/Debit Card Number(Required)

Expiration Date(Required)

CVV(Required)

Billing Zip Code(Required)

Please type Full Name for Signature(Required)

Today's Date(Required)

Discount Code (if applicable)

"Bill To" Company Information

The "Bill To" section refers to the entity or person responsible for receiving and paying the invoice. In most cases, this is the same as the service location. However, if your invoices need to be sent to a different person, department, or address (such as a corporate office or an accounting department), please provide the correct billing details below. If your billing information is the same as your service location, you can skip this section.

"Bill To" Company Name

EX: Restaurant Group, LLC

Corporate Address

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

Corporate Phone

Corporate Email