Authorize.Net Account Setup Form

The Company listed below hereby authorizes Authorize.Net to initiate a debt entry to Company’s credit card account and to debit the same to such account for the amount listed below. Company acknowledges that the origination of credit transactions to the Company’s account must comply with the provisions of US law.

Company Information

Principle Name
Card Number
Billing Address
Postal Code

Merchant Account Configuration

Merchant ID
Email Address
Date of Birth
Expiration Date
Merchant Account


Authorize.NET Payment Account Fees:
Setup Fee: $ 0.00
Monthly Gateway Fee: $ 25.00*
Per-Transaction Fee: $ 0.10*
Batch Fee $ 0.10
Late Payment Fee: $ 10.00 per occurance
Abandoned Account Fee: $ 10.00 per month

*Monthly Gateway and Per-Transaction Fee: Authorize.Net shall charge Company a monthly Gateway fee and Per Transaction fee in the amounts providedabove; billing shall commence upon the creation of the account. Such fees will be billed automatically on a monthly basis to the bank account provided.

Authorization: By signing below, the individual signing this application [Company] certifies, acknowledges and agrees that: 1. Applicant is an authorized principal,partner, officer or other authorized representative of Company that is authorized to bind Company to contractual obligations; 2. Authorize.Net may shareinformation contained in these setup forms with its service partners for the purpose of establishing a Merchant Account, if applicable; 3. Billing for the Authorize.Net Payment Gateway Account in the amounts set forth above shall commence upon [Company’s] execution below; and 4. Company agrees to be bound by theterms and conditions of the Authorize.Net Payment Gateway Merchant Service Agreement incorporated herein by the reference and locate at the listed Web URL.

Effective Date: The date that Authorize.Net recieved the Company’s completed Account Setup Form and Authorization for Credit Card transaction.

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