Please complete and sign the form below, then scan and e-mail to This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or mail it to our office address:
Remotely Yours, Inc.
#1, 4216 – 10th Street NE
Calgary, AB T2E 6K3
Check the type of card that you wish to authorize for transactions: VISA _______ MasterCard _______
Bank Name of Credit Card: ________________________________________________
Credit Card #: ______________-_______________-______________-______________
Expiration Date on Credit Card: __________ / __________
Name of Credit Card Holder: ___________________________________________________________________
Billing Address of Credit Card Holder:
____________________________________________________________________________________________
____________________________________________________________________________________________
Phone Number of Credit Card Holder: (__________) _________ - _________________
I authorize Remotely Yours, Inc. (RY), to keep this information on file, for the following:
_____ 1-time payment of $___________________;
_____ 1-time payment to clear up statement dated _______________________________________;
_____ monthly invoicing (I agree and understand that RY will forward copies of all invoices, to the e-mail address I have previously provided, and that I will have 14 days to question said invoice(s), after which RY will automatically process the payment, by charging it to my above-listed credit card in the last week of the month following invoice date.
I further understand that I may update this information, by e-mail (to This e-mail address is being protected from spambots. You need JavaScript enabled to view it ) or telephone (to 403-617-0909). I may cancel this authorization, with 30 days written notice, to the RY address shown on my most recent invoice, in which case I will provide a prepayment, of services, by an alternate method, to be approved by RY. If cancellation of services is being requested, at the same time, then I agree to follow the process given on RY website “remotelyyours.com”.
By signing this authorization, I acknowledge that I have read and agree to all of the above. All information given is complete and accurate.
Signature of Card Holder: __________________________________________________
Printed Name of Card Holder: _______________________________________________
Date of Signature: _________________________________________________________
Office Use Only:
Date Received:___________________________________________________________
Posted to QB on ____________________________________ by ________________________________________.
Posted to Chase on __________________________________by_________________________________________.
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(RY/Auto CC Authorization 092411) |