Credit Card Auth Form | Coastal Inspection

One Time Credit Card Authorization Form

For escrow purposes: The credit card information will be securely held until payment from the escrow office clears. Once payment is received from the escrow account, this credit card information will be destroyed. If escrow fails to close within 60 days, or you cancel escrow for any reason, the credit card on file will be charged the full amount of the inspection.

For cancellation/appointment hold purposes: The credit card information will be securely held. If the cancellation policy has been violated (cancelled within 24 hours of the inspection), this provides authorization to charge the credit card on file.

By completing this form, you give us permission to debit the account for the amount indicated on your home inspection agreement. This permission is for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account. Please complete the information below.

Inspection Address:

Inspection Date:

Close of Escrow Date:

First Name (as appears on credit card)

Last Name (as it appears on credit card)

Credit Card Number:

Expiration date:

3 or 4 digit CVV code:

Billing Address

Phone Number

By checking this box, I authorize Coastal Inspection Services to charge the credit card as indicated in this authorization form according to the terms outlined above. I certify that I am the authorized user of this credit card and that I will not dispute the payment with the credit card company; so long as the transaction corresponds to the terms indicated in this form.

Thank you!

Great People. Amazing Service. Quality Results.

(949) 481-2501

One Time Credit Card Authorization Form

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