Credit Card Authorization Form Billing Name:* First Last Company: Billing Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Billing Phone:*Email:* Type of Credit Card:*<Select One>AmexDiscoverMastercardVisaOtherCredit Card #:*Exp. Date:* MM slash DD slash YYYY CVV Number:* Amount Authorized:*Please enter a number from 197 to 50000.Payment Type:* Monthly Ad Budget Monthly Platform Fee $197 Set Up Fee $197 Management Fee 20% Other Check all that applyPayment Frequency:*<Select One>One Time PaymentBi-Weekly PaymentMonthly PaymentAuthorization* I authorize this paymentThe name of the billing contact is authorized to make this payment and granting MarketShare Media permission to process this payment and / or set up automatic payments for downpaymentmd.org related services.Terms & Conditions* I agree to terms & conditions1.) If this payment is part of a client / lender or other type of marketing budget split the client of record will be responsible for any outstanding balances in the event the participating partner stops, declines, or disputes payments including platform fees and / or marketing budget payments. The client will be responsible for any fees incurred by DownpaymentMD.org / Marketshare Media due to charge backs or other banking incurred fees as related to this agreement between Marketshare Media and the client. 2.) Client and entities participating in any type of budget splits may cancel services with Marketshare Media / DownpaymentMD.org during first 30 days without written notice. After first thirty days of service a 30-day notice is required to terminate service by completing a “service cancellation form”. Phone, email, or other types of communication will not be accepted. 3.) Marketshare Media makes no claims or warranty to the number of leads a client may receive or to the quality of said leads. Lead volume is based on many factors including budget, market, geo-location, competition, and other factors that Marketshare Media has no control over. 4.) While Marketshare Media will work with clients to connect to a CRM of choice, the official mechanism of lead delivery will be the dashboard provided on downpaymentMD.org or third-party lead management platform provided by Marketshare Media. If client utilizes a CRM that is not easily supported, Marketshare Media may provide client with a quote for professional services to have integration work completed. 5.) All ad budget is billed directly to the source such as Google or Facebook and non-refundable. All client forms are located at https://downpaymentmd.org/forms/Notes / Comments:CommentsThis field is for validation purposes and should be left unchanged.