Submit Payment Details

Credit Card Authorization Form

"*" indicates required fields

This form will be transmitted securely to Bayshore Interactive.

Please provide the following information as it is registered with your financial institution. All information sent is encrypted and Bayshore Interactive adheres to the highest standards for account data protection.

Card Holder Name*

First Last

Company Name

Credit Card Number*

No Dashes Required

CVV*

Security Code

Expiration Month*

Expiration Year*

Card Type*

Billing Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Recurring / Periodic Billing: I hereby authorize Bayshore Interactive to charge the indicated credit card on a periodic basis for the amount due under my agreement with Bayshore Interactive as indicated below. This Recurring Payment Authorization/Periodic Charge shall remain in force until cancelled by me in writing.

Check "I Agree" to indicate that you've read and agree to the above*

I Agree

Please list what services the credit card authorization is for:

I hereby authorize Bayshore Interactive to charge the indicated credit card. I agree that this is either a one time or periodic charge that will be made as indicated above. To terminate the recurring billing process, if selected, I must cancel in writing, otherwise the account will be manually invoiced and payment made via check, money order or wire. I understand that all account cancellations must be made in writing. I will not dispute Bayshore Interactive's recurring billing with my credit card issuer so long as the amount in question was for services rendered prior to my canceling my account in the manner required. I guarantee and warrant that I am the legal cardholder for this credit card and that I am legally authorized to enter into this one time or recurring billing agreement with Bayshore Interactive.

Name

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