Please complete and submit this authorization form to set up automatic payments for your salon services or product purchases.

Customer Information

Address

Street Address

City

State

Country

Postal Code

First Name *

Last Name *

Phone *

Email *

Billing Method:

(Please check one)

Authorization Details

I authorize Salon on 3rd to charge my designated bank account or credit/debit card for recurring payments as indicated below:

Bank Account Details (if applicable)

Account Number

Bank Name

Account Type (Checking/Savings)

Routing Number

Credit/Debit Card Details (if applicable)

Date

Billing Zip Code

(Please provide card information below or attach a secure card authorization form if required)

Card Number

Expiration Date

CVV

Payment Authorization & Terms

I authorize Salon on 3rd to initiate recurring payments from my designated account/card for services, retail, or membership fees.
Payments will be processed on (specify frequency, e.g., monthly, quarterly, etc.) basis, beginning on //____.
I understand I can update or cancel this authorization in writing with [Salon on 3rd] with at least 30 days' notice.

Signature *

Date

For Office Use Only

Processed By

Date