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Payment authorization form template

Customer permission to charge a payment method.

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How to make a payment authorization form

  1. 1

    Check the questions: rename, add or delete any field, or change how it’s answered.

  2. 2

    Add your organisation’s name, a contact line and your logo if you like.

  3. 3

    Choose fillable PDF, printable PDF, Word or HTML, and the paper size.

  4. 4

    Download the payment authorization form and share it, print it or add it to your website.

About this payment authorization form

A payment authorization form records a customer’s permission for a business to charge them: one time, or regularly for a membership, subscription, school fees or a service plan. It states the amount, frequency, start date and how to cancel, and the customer signs.

For security, this template records only the last four digits of a card or account. Never collect full card numbers, CVV codes or PINs on paper or PDF; set up the actual payment through your bank, payment gateway, UPI AutoPay or e-mandate.

What’s on the payment authorization form

The template has 4 sections and 14 questions. Every one can be renamed, moved or deleted.

  • Customer: Name; Phone; Email; Account or customer number
  • Payment: Amount; Frequency (choose one: One time, Weekly, Monthly, Quarterly, Yearly); Start date; End date (optional); For
  • Payment method: Method (choose one: Card, Bank account, UPI AutoPay, e-mandate); Card or account – last 4 digits only; Name on card or account
  • Authorization: Agreement: “I agree to the terms above.”; Signature with date

Tips

  • Tell customers how and when they can cancel.
  • Send a reminder before each recurring charge if the amount changes.
  • Store signed forms securely and destroy them when no longer needed.

Four ways to save it

A fillable PDF has typing boxes, tick boxes and choices built in. A printable PDF gives clean boxes and writing lines for pen and paper. The Word file can be edited further, and the HTML code adds the same questions to a website. Browse more form templates, or design a completely different layout in the custom form builder.

Frequently asked questions

Why only the last four digits?

Keeping full card numbers on paper or in PDFs is a security risk and breaks card industry rules. The last four digits identify the card without exposing it.

Does this set up an automatic payment?

No. It records consent. The automatic payment itself must be set up through your bank, payment provider, UPI AutoPay or e-mandate.

Can I add my logo to the payment authorization form?

Yes. Add your organisation’s name, a contact line and a logo in “Form details”. The logo is placed into the file on your device and is never uploaded.

Can I change the questions on the payment authorization form?

Yes. Rename any question, change its answer type (short answer, tick boxes, rating, table and more), move it, or delete it. You can also add whole new sections.

Can people fill in this payment authorization form on a phone?

Yes. Choose “Fillable PDF” and send the file. It opens in the Files or Drive app on Android, Files on iPhone, and any browser on a computer, where people can type their answers and save the result.

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