Please sign and complete this form to authorize Ears of Experience to make a one-time debit to your credit card listed below.
By signing this form, you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account.
Please complete all field. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.