Payment Approval Form

First Name

Last Name

Phone Number

Your email

Amount

Payment Method
VisaMasterCardAmerican ExpressOther
Reason of Payment

By signing and submitting this form, the undersigned client ("Client") provides their full authorization to A&A Appliance Leasing, Inc. ("Company") to process payment according to the following terms:

1. Payment Authorization Grant

The Client authorizes A&A Appliance Leasing, Inc. and its authorized agents to use the payment information provided herein to charge the exact dollar amount specified in the Amount Field of this document. This charge is authorized to be initiated:

• Over the phone by an authorized agent of the Company.

• Online via the Company's secure payment system.

2. Acknowledgment and Agreement to Pay

The Client affirms they are the authorized user of the payment method provided and confirms they have reviewed and agreed to the amount documented in the Amount Field. The Client agrees that A&A Appliance Leasing, Inc. is authorized to process a single charge for that specific total.

3. Usage and Retention of Information

The Client grants A&A Appliance Leasing, Inc. permission to retain and use the provided payment information solely for the purpose of processing the authorized charge for the services or products specified in the underlying agreement.

4. Binding Effect

This authorization is effective immediately upon submission and remains valid until the specified amount has been successfully charged and paid in full.