Billing & Recurring Payment Form

This is a secure page that will allow you to safely enter credit card information. You can also call our office at 816-476-7776 to set up a payment option.

Please fill out the credit card authorization form below.

All hourly or project invoicing will not be automatically charged to the card on file unless authorized. These charges would only be for all monthly, quarterly, and yearly recurring charges.

Cards on File will be used for:

* Recurring payments -This would include things such as domain renewals, hosting renewals, SSL certificate renewals, and quarterly security updates.

Business Name*
Credit Card Type*
Credit Card Number*
Expiry Date*
Cardholder's Name*
First Last
(As shown on card)
Billing ZIP Code*
ZIP / Postal Code
Card CVV Number*
(3 or 4 digit code on back)
Confirmation*
- I agree to the terms above, and approve this credit card to be used for all recurring payments. I understand Elemeno Digital will set up your automatic payments for recurring services only. I understand total charges will appear on my monthly credit card statement and I will also receive a paid receipt for all charges.
E-Signature*
Print Name*
Date*
MM slash DD slash YYYY

Billing & Recurring Payment Form

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