I authorize The Credit Tracker/TekltOut LLC to obtain charges for Outsourced Disputing from my payment account listed below. I will be charged the amount indicated on my billing statement emailed to my email on file at the end of each billing period. A receipt for each payment will be provided to me to my email on file. I agree that no prior-notification will be provided, unless the dates of collection or fees change, in which case I will receive notice at least 20 days prior to the payment being collected.  I authorize The Credit Tracker/TekItOut to store my payment method for collection of my Outsourcing Fees for Dispute work. 

I,   Authorize The Credit Tracker/TekltOut LLC to charge the Account indicated below for Out Sourcing Dispute work.

PLEASE PROVIDE ACCOUNT INFORMATION BELOW AS YOUR PAYMENT METHOD
 

Bank Account Information 

Account name:                                                     

Bank name:                                                     

Account number:                                                   

Routing number:       

Credit Card Details

Card Type:  

Cardholder Name:                                                     

Account Number:                                                      

Expiration Date:                                      

CVV:                         

 
Billing Information for payment method 

Billing Address:                                                     

Phone #:                                                      

City, State, Zip:                                                     

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify The Credit Tracker/TekltOut LLC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I acknowledge that the origination of transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this Account and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorization form.