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About Us
Services
Portfolio
Testimonials
Our Blog
Shop
Contact Us

Recurring Payment Authorization

In order to process your credit card on a recurring basis, we need to have your permission. We will not share this information with anyone. Review our Privacy Policy .

*REQUIRED FIELDS

Client Information

Company Name(Required)

Client Name(Required)

First Last

email(Required)

Phone(Required)

Payment Information

Service(Required)

Please select all that apply.

Web Hosting

Website Management

Domain Name Registration

Google Ads (formerly Google AdWords)

Retainer Services

Other

Other(Required)

Please list service if other.

Recurring Amount(Required)

Please contact us if you are unsure about this amount. Recurring payments will not be generated if the amount is incorrect.

Frequency(Required)

Please note that some restrictions and special offers may or may not apply.

Weekly

Monthly

Yearly

Start Date(Required)

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

No End Date

Credit Card Information

Card type(Required)

Visa

MasterCard

American Express

Discover

Name(Required)

As it appears on credit card.

First Middle Last

Address(Required)

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

Card Number(Required)

Expiration Date Month(Required)

Expiration Date Year(Required)

Security Code(Required)

(3 or 4 digit number located on the back of card)

This is a commercial card

Notify me by email when my credit card is processed.

Authorization

I herby authorize GINGALLEY Web Design & Promotions to automatically bill the credit card listed above.(Required)

I agree

I disagree

Name(Required)

First Last

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Name

This field is for validation purposes and should be left unchanged.

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