Automatic Credit Card Billing Authorization
Please print and complete form.
J Byous Company
An Affair to Remember, Byous Photography
If you would enjoy the convienence of automatic billing, simply complete the Credit Card Information section below and sign the form.  All requested information is required.  Upon approval, we will automatically bill your credit card for the amount indicated and your total charges will appear on your monthly credit card statement.  You may cancel this automatic billing authorization at any time by contacting us.
Customer Information
Customer name:
Customer account number:
(To be completed by merchant)
Phone: (Include area code)
Address:
(Address 2:)
City:
State:
Zip or Postal code:
Country:
Payment Information
I authorize J Byous Co, dba An Affair to Remember, Byous Photography, to automatically bill the card listed below as specified.
Amount:  $
Frequency:
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Quarterly
Semi Annually
Annually
(Check only one)
Start billing on:
Month
Day
Year
End billing when:
Month
Day
Year
Contract expires:
Customer provides written cancellation:
Credit Card Information
Credit Card Type:
J Byous Co, dba An Affair to Remember, Byous Photography accepts the following credit cards: Visa, MasterCard, American Express, Discover.
Credit Card Number:
Cardholder's name:(as shown on card)
Expiration date:
Cardholder's Zip code:
(from credit card billing address)
Month
Day
Year
Customer's signature:

Date:
Address:
(Address 2:)
City:
State:
Zip or Postal code:
Country:
Shipping address if different:
Fax to: 912-335-7749, attach to email at jbyous@jbyous.com or mail to J Byous Co. 1230 E. 51st St. Savannah, GA 31404, USA
Non-refundable deposit (If applicable):  $