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Christ-Centered Biblical Counseling for Men

Christ-Centered Biblical Counseling

Recurring Payment Card Authorization Form for PeaceBrooke Biblical Counseling

First Name

Last Name

give Peacebrooke Biblical Counseling permission to charge my card on record ending in the following four digits

the following amount

every

for the following number of biblical counseling sessions in each of the above weeks, dates or quarters:

Please send my receipts to the following email address:

I understand that I may cancel this agreement at anytime by sending notification to rusty@peacebrooke.org. Typing my name below constitutes my written authorization to this agreement by signature.

Signed on this day of

YYYY