American Home Services, Inc.
10351 N. 6580 W.
Highland, UT 84003
(801-513-4559
www.americanhomeservicesinc.com
10351 N. 6580 W.
Highland, UT 84003
(801-513-4559
www.americanhomeservicesinc.com
Payment Authorization Form
Sign and complete this form to authorize American Home Services, Inc. to make weekly debits to your credit card or checking account listed below. You will receive an invoice every Monday, indicating how many leads you received and the total amount you owe for the previous week. We can credit your account for any leads that have invalid addresses, phone numbers or bogus names. (We reserve the right to audit the credit request to verify the information).
By signing this form you give us permission to debit your account for the amount of the invoice on each Monday. This is permission for a single weekly transaction only, as agreed upon, and does not provide authorization for any additional unrelated debits to your account.
Please complete the information below:
I, ________________________________________________________ authorize American Home Services, Inc. to charge my credit card
(print full name)
account or bank account indicated below on each Monday following the weeks my company receives business leads.
The cost for the leads will be $12.00, $25.00 or $58.00 each. Cost is determined by the potential value of the lead provided. Service Leads, single windows, garage doors and repairs will be $12.00, Landscaping and Fencing type leads will be $25.00. Siding, Windows, Basements, Bathrooms and Kitchen type leads will be $58.00 each. Exclusive leads are $120.00 each.
Business Name _________________________________________ Phone# _________________________
Billing Address __________________________________________ Email __________________________
City, State, Zip __________________________________________ Cell # __________________________
Account Type: 0 Visa 0 MasterCard 0 AMEX 0 Discover 0 Checking/Savings
Card/Account Holder Name ____________________________________
Card Number ____________________________________________
Expiration Date ________________
CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX) _______
Routing Number ____________________________________________
Account Number ____________________________________________
0 Text Leads Provider_____________ Phone # ________________________ 0 Email Leads
SIGNATURE _______________________________________________________________ Date ____________________________
I authorize American Home Services, Inc. to charge the account(s) indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above and for the amount indicated on the weekly invoice only. I certify that I am an authorized user of this credit card or bank account. Any unpaid invoice will result in immediate interruption of leads, until invoice is paid.
By signing this form you give us permission to debit your account for the amount of the invoice on each Monday. This is permission for a single weekly transaction only, as agreed upon, and does not provide authorization for any additional unrelated debits to your account.
Please complete the information below:
I, ________________________________________________________ authorize American Home Services, Inc. to charge my credit card
(print full name)
account or bank account indicated below on each Monday following the weeks my company receives business leads.
The cost for the leads will be $12.00, $25.00 or $58.00 each. Cost is determined by the potential value of the lead provided. Service Leads, single windows, garage doors and repairs will be $12.00, Landscaping and Fencing type leads will be $25.00. Siding, Windows, Basements, Bathrooms and Kitchen type leads will be $58.00 each. Exclusive leads are $120.00 each.
Business Name _________________________________________ Phone# _________________________
Billing Address __________________________________________ Email __________________________
City, State, Zip __________________________________________ Cell # __________________________
Account Type: 0 Visa 0 MasterCard 0 AMEX 0 Discover 0 Checking/Savings
Card/Account Holder Name ____________________________________
Card Number ____________________________________________
Expiration Date ________________
CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX) _______
Routing Number ____________________________________________
Account Number ____________________________________________
0 Text Leads Provider_____________ Phone # ________________________ 0 Email Leads
SIGNATURE _______________________________________________________________ Date ____________________________
I authorize American Home Services, Inc. to charge the account(s) indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above and for the amount indicated on the weekly invoice only. I certify that I am an authorized user of this credit card or bank account. Any unpaid invoice will result in immediate interruption of leads, until invoice is paid.
