Credit Card Authorization Form Personal Support Worker Service – Antonietta Giacomel

Name on Credit card *

Card Number

Expiration date (mm/yy)

3 digit back of card

Cardholder Postal code(from credit card billing address):

YOUR NAME *

I authorize Universal Health Hub to charge my credit card on a weekly basis for personal care services provided to Antonietta Giacomel at the rate of $35.00 per hour. Charges will be processed weekly based on the scheduled care services provided during that billing period. I also authorize Universal Health Hub to charge an additional 3% credit card transaction fee on each payment processed.

I consent