Credit Card Authorization Form

This form is used for initial entry or providing alternate credit or debit cards for Ark House to use for automatic billing for background checks, security deposits, weekly rent, or other fees that may be assessed for failure to follow apartment rules such as putting out the trash at inappropriate times.

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CREDIT CARD AUTHORIZATION

PLEASE COMPLETE ALL FIELDS:

This agreement is between Ark House, the credit card owner, and the applicant(s) for an Ark House apartment.

The patient or their representative, , certifies that , the cardholder, has authorized Ark House to charge the credit/debit card listed below for $20.00 for the patient's background check. Ark House will pay for the background checks for each of the other applicants listed on the Ark House application. I (person submitting this form) further certify that I have permission from each of the applicants to order the background checks in support of the Ark House occupancy application. Further, it is agreed that the background check fee is NONREFUNDABLE!

This credit/debit card authorization will also be used to pay for rent if/when the patient and/or occupants take possession of an Ark House apartment. The initial payment will include the security deposit, a partial week consisting of the days leading up to next Friday, and one full week in advance. Future payments will be due on subsequent Friday’s paying in advance for one week’s rent (All rent is due one week in advance).

You may cancel this authorization at any time by contacting us in writing or by email. This authorization remains in effect until canceled. If canceled, you must vacate the apartment immediately or provide an alternate charge/debit card.

CREDIT CARD INFORMATION
PATIENT'S Name: <== This MUST be Patient's First and Last Name

Card Type:MasterCardVISADiscoverAMEXDiners ClubDebit Card

Card Number [NO Dashes]:

Cardholder Cell Phone:

Card Holder Email:

Expiration Date [Include '/']: <== 2 digit Month / 2 digit Year

Security Code or CVV# (on back):

I was authorized by the credit/debit card owner and ALL persons listed on the Ark House application to permit Ark House to charge the credit card above for and to perform background checks required for Ark House occupancy and for rent payments should the patient and/or other occupants move into the Ark House. I understand that this form will be saved to file for future transactions on this account and for a period of time afterward.

Signed by:
Signed by Email:

I accept all terms listed in this Credit/Debit Card Authorization.