Form: Credit Card Form for iProspector Service

Thank you for choosing this service, which will enable you to effectively market insurance online. By completing this form, you give GPAgency permission to automatically bill your credit card $50 the first of each month. To discontinue this service, please provide a 60-day notice to GPAgency -- via email: melinda@gpagency.com | call: (800) 283-8376. On this form, please provide the required information to process your payment.
First & Last Name (as it appears on your credit card)*
Credit Card Number*
Credit Card Type*
- Visa
- MasterCard
- AMEX
- Discover
Expiration Date (e.g., 06/24)*
CVV2 (3-digit number on back of Visa/MC, 4 digits on front of AMEX)*
Address Associated with this Credit Card:
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone Number Associated with this Credit Card*
Email Address Associated with this Credit Card*
CONSENT
- I authorize GPAgency to charge the credit card indicated on this authorization form according to the terms outlined above. This payment authorization is for a monthly charge of $50 for the iProspector service described above. I certify that I am an authorized user of this credit card. I will not dispute the payment with my credit card company so long as the transaction corresponds to the terms indicated in this form.
If you have questions pertaining to your credit card payment, please contact Dawn@gpagency.com | (919) 834-7937.