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Charge Agreement For Services Contracted From Planet Massage of Fort Lauderdale

CREDIT CARD CHARGE AUTHORIZATION AGREEMENT:
As the holder of the credit or debit card identified by the last four digits included in cleint information section of this agreement, I hearby authorize Planet Massage to charge the agreed upon charges as indicated in this document.  I confirm the charges to be correct and agree to payment as per my credit card agreement.  I have read this entire agreement and understand that I will be held fully responsible for its terms and charges. Credit Card information may be saved in our system and with your approval, we may use this information for any future charges you are responsible for.

I attest that I am an authorized signer on the account indicated in this agreement and as provided to Planet Massage. I agree that all sales are final and that there are no refunds, cancellations or rescheduling without a prior agreement in writing with Planet Massage. I agree to the cancellation policy as supplied by Planet Massage in the proposal, invoice or service agreement. If no such agreement exists, I agree to the current cancellation policy found at http://planetmassage.com/cancellation_policy/

I understand that customary therapist gratuities have not been added to the base service price, unless otherwise specified in your proposal, invoice or service agreement. While this is generally at the customers discression, customary therapist gratuities generally are 15-25% for excellent service.

I Agree

May 21, 2019

First Card Holder Name

First Name*

Middle Name

Last Name*

Phone*
First Card Holder Date of Birth*
I certify that I am 18 years of age or older
First Card Holder Service Request and Payment Information
Type Of Credit Card *
Visa
Mastercard
American Express
Discover

Last four numbers of my credit card (ONLY, do not enter full card number) *

Card Security Code *

Amount I am authorizing Planet Massage to charge in US dollars *

Brief description of services for which I am authorizing payment for: *

Date Services to be performed or start date if multiple days *

Company Name (Required if business)

My title at company, (required if business)

Is this a recurring charge? If so, what is the frequency and end date?

Gratuities: I am also authorizing charges for a gratuity in the following amount or percentage, in addition to the base amount indicated above. Unless otherwise stated in proposal, invoice or agreement, I may adjust this amount after service by notifying Planet Massage in writing.

Address or location for which services are to be performed at

Contact person at event with phone and cell number, if applicable

Additional Information
First Card Holder Signature*
Second Card Holder Name

First Name*

Middle Name

Last Name*
Second Card Holder Date of Birth*
Second Card Holder Service Request and Payment Information
Type Of Credit Card *
Visa
Mastercard
American Express
Discover

Last four numbers of my credit card (ONLY, do not enter full card number) *

Card Security Code *

Amount I am authorizing Planet Massage to charge in US dollars *

Brief description of services for which I am authorizing payment for: *

Date Services to be performed or start date if multiple days *

Company Name (Required if business)

My title at company, (required if business)

Is this a recurring charge? If so, what is the frequency and end date?

Gratuities: I am also authorizing charges for a gratuity in the following amount or percentage, in addition to the base amount indicated above. Unless otherwise stated in proposal, invoice or agreement, I may adjust this amount after service by notifying Planet Massage in writing.

Address or location for which services are to be performed at

Contact person at event with phone and cell number, if applicable

Additional Information
Third Card Holder Name

First Name*

Middle Name

Last Name*
Third Card Holder Date of Birth*
Third Card Holder Service Request and Payment Information
Type Of Credit Card *
Visa
Mastercard
American Express
Discover

Last four numbers of my credit card (ONLY, do not enter full card number) *

Card Security Code *

Amount I am authorizing Planet Massage to charge in US dollars *

Brief description of services for which I am authorizing payment for: *

Date Services to be performed or start date if multiple days *

Company Name (Required if business)

My title at company, (required if business)

Is this a recurring charge? If so, what is the frequency and end date?

Gratuities: I am also authorizing charges for a gratuity in the following amount or percentage, in addition to the base amount indicated above. Unless otherwise stated in proposal, invoice or agreement, I may adjust this amount after service by notifying Planet Massage in writing.

Address or location for which services are to be performed at

Contact person at event with phone and cell number, if applicable

Additional Information
Fourth Card Holder Name

First Name*

Middle Name

Last Name*
Fourth Card Holder Date of Birth*
Fourth Card Holder Service Request and Payment Information
Type Of Credit Card *
Visa
Mastercard
American Express
Discover

Last four numbers of my credit card (ONLY, do not enter full card number) *

Card Security Code *

Amount I am authorizing Planet Massage to charge in US dollars *

Brief description of services for which I am authorizing payment for: *

Date Services to be performed or start date if multiple days *

Company Name (Required if business)

My title at company, (required if business)

Is this a recurring charge? If so, what is the frequency and end date?

Gratuities: I am also authorizing charges for a gratuity in the following amount or percentage, in addition to the base amount indicated above. Unless otherwise stated in proposal, invoice or agreement, I may adjust this amount after service by notifying Planet Massage in writing.

Address or location for which services are to be performed at

Contact person at event with phone and cell number, if applicable

Additional Information
Fifth Card Holder Name

First Name*

Middle Name

Last Name*
Fifth Card Holder Date of Birth*
Fifth Card Holder Service Request and Payment Information
Type Of Credit Card *
Visa
Mastercard
American Express
Discover

Last four numbers of my credit card (ONLY, do not enter full card number) *

Card Security Code *

Amount I am authorizing Planet Massage to charge in US dollars *

Brief description of services for which I am authorizing payment for: *

Date Services to be performed or start date if multiple days *

Company Name (Required if business)

My title at company, (required if business)

Is this a recurring charge? If so, what is the frequency and end date?

Gratuities: I am also authorizing charges for a gratuity in the following amount or percentage, in addition to the base amount indicated above. Unless otherwise stated in proposal, invoice or agreement, I may adjust this amount after service by notifying Planet Massage in writing.

Address or location for which services are to be performed at

Contact person at event with phone and cell number, if applicable

Additional Information
Sixth Card Holder Name

First Name*

Middle Name

Last Name*
Sixth Card Holder Date of Birth*
Sixth Card Holder Service Request and Payment Information
Type Of Credit Card *
Visa
Mastercard
American Express
Discover

Last four numbers of my credit card (ONLY, do not enter full card number) *

Card Security Code *

Amount I am authorizing Planet Massage to charge in US dollars *

Brief description of services for which I am authorizing payment for: *

Date Services to be performed or start date if multiple days *

Company Name (Required if business)

My title at company, (required if business)

Is this a recurring charge? If so, what is the frequency and end date?

Gratuities: I am also authorizing charges for a gratuity in the following amount or percentage, in addition to the base amount indicated above. Unless otherwise stated in proposal, invoice or agreement, I may adjust this amount after service by notifying Planet Massage in writing.

Address or location for which services are to be performed at

Contact person at event with phone and cell number, if applicable

Additional Information
Seventh Card Holder Name

First Name*

Middle Name

Last Name*
Seventh Card Holder Date of Birth*
Seventh Card Holder Service Request and Payment Information
Type Of Credit Card *
Visa
Mastercard
American Express
Discover

Last four numbers of my credit card (ONLY, do not enter full card number) *

Card Security Code *

Amount I am authorizing Planet Massage to charge in US dollars *

Brief description of services for which I am authorizing payment for: *

Date Services to be performed or start date if multiple days *

Company Name (Required if business)

My title at company, (required if business)

Is this a recurring charge? If so, what is the frequency and end date?

Gratuities: I am also authorizing charges for a gratuity in the following amount or percentage, in addition to the base amount indicated above. Unless otherwise stated in proposal, invoice or agreement, I may adjust this amount after service by notifying Planet Massage in writing.

Address or location for which services are to be performed at

Contact person at event with phone and cell number, if applicable

Additional Information
Eighth Card Holder Name

First Name*

Middle Name

Last Name*
Eighth Card Holder Date of Birth*
Eighth Card Holder Service Request and Payment Information
Type Of Credit Card *
Visa
Mastercard
American Express
Discover

Last four numbers of my credit card (ONLY, do not enter full card number) *

Card Security Code *

Amount I am authorizing Planet Massage to charge in US dollars *

Brief description of services for which I am authorizing payment for: *

Date Services to be performed or start date if multiple days *

Company Name (Required if business)

My title at company, (required if business)

Is this a recurring charge? If so, what is the frequency and end date?

Gratuities: I am also authorizing charges for a gratuity in the following amount or percentage, in addition to the base amount indicated above. Unless otherwise stated in proposal, invoice or agreement, I may adjust this amount after service by notifying Planet Massage in writing.

Address or location for which services are to be performed at

Contact person at event with phone and cell number, if applicable

Additional Information
Ninth Card Holder Name

First Name*

Middle Name

Last Name*
Ninth Card Holder Date of Birth*
Ninth Card Holder Service Request and Payment Information
Type Of Credit Card *
Visa
Mastercard
American Express
Discover

Last four numbers of my credit card (ONLY, do not enter full card number) *

Card Security Code *

Amount I am authorizing Planet Massage to charge in US dollars *

Brief description of services for which I am authorizing payment for: *

Date Services to be performed or start date if multiple days *

Company Name (Required if business)

My title at company, (required if business)

Is this a recurring charge? If so, what is the frequency and end date?

Gratuities: I am also authorizing charges for a gratuity in the following amount or percentage, in addition to the base amount indicated above. Unless otherwise stated in proposal, invoice or agreement, I may adjust this amount after service by notifying Planet Massage in writing.

Address or location for which services are to be performed at

Contact person at event with phone and cell number, if applicable

Additional Information
Tenth Card Holder Name

First Name*

Middle Name

Last Name*
Tenth Card Holder Date of Birth*
Tenth Card Holder Service Request and Payment Information
Type Of Credit Card *
Visa
Mastercard
American Express
Discover

Last four numbers of my credit card (ONLY, do not enter full card number) *

Card Security Code *

Amount I am authorizing Planet Massage to charge in US dollars *

Brief description of services for which I am authorizing payment for: *

Date Services to be performed or start date if multiple days *

Company Name (Required if business)

My title at company, (required if business)

Is this a recurring charge? If so, what is the frequency and end date?

Gratuities: I am also authorizing charges for a gratuity in the following amount or percentage, in addition to the base amount indicated above. Unless otherwise stated in proposal, invoice or agreement, I may adjust this amount after service by notifying Planet Massage in writing.

Address or location for which services are to be performed at

Contact person at event with phone and cell number, if applicable

Additional Information
Card Holder Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Service Request and Payment Information
Type Of Credit Card *
Visa
Mastercard
American Express
Discover

Last four numbers of my credit card (ONLY, do not enter full card number) *

Card Security Code *

Amount I am authorizing Planet Massage to charge in US dollars *

Brief description of services for which I am authorizing payment for: *

Date Services to be performed or start date if multiple days *

Company Name (Required if business)

My title at company, (required if business)

Is this a recurring charge? If so, what is the frequency and end date?

Gratuities: I am also authorizing charges for a gratuity in the following amount or percentage, in addition to the base amount indicated above. Unless otherwise stated in proposal, invoice or agreement, I may adjust this amount after service by notifying Planet Massage in writing.

Address or location for which services are to be performed at

Contact person at event with phone and cell number, if applicable

Additional Information
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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