Payment Authorization Form



Schedule your payment to be automatically deducted from your bank account, or charged to your Visa, MasterCard, American Express or Discover Card. Just complete and sign this form to get started! For questions or comments, please call or e-mail us: 214-382-2727 - support@ciaresearch.com

Account Holder Information

Company Name *:
Name on Account*:
Phone Number*:
Billing Street Address *:
City *:
State *:
Zip Code *:


Type of Payment:	ACH Credit Card

E-Sign Document

To electronically submit this Payment Authorization Form, type your first and last name and email address. Next, draw your signature in the box below. If you are on a smart phone or tablet, use your finger to draw the signature. By submitting this Payment Authorization Form, you are agreeing that all information submitted is valid and correct, and authorizing that Clear Investigative Advantage can charge your credit card per your selection above, with an additional 3.00% processing fee per transaction. The electronic transmittal of this document shall not affect the legal effect, validity or enforceability of this document. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Clear Investigative Advantage in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that Clear Investigative Advantage may at its discretion attempt to process the charge again within 30 days. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.
Type your first and last name:
Type your email address:
Type today's date (mm/dd/yyyy):

Draw your signature below Draw Signature Clear
Submit Form

Enter the security code word in the picture in the field below, then submit this form.