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Payment Authorization Form – Nexgen Placement LLC
Full name
*
Email
*
Billing address
*
Amount (USD)
*
Payment stage
*
Mode of payment
*
A
Credit card
B
Debit card
C
Mobile payment (Apple Pay, Google Pay)
When do you plan to make this payment?
*
A
Today
B
Tomorrow
C
Within 2–3 days
D
Within a week
E
More than a week from now
Are you paying from your own account or card?
*
A
Yes
B
No
Consent
*
Please tick all four to continue.
I authorize this payment. If the card belongs to someone else, I confirm the cardholder has approved it.
I can cancel within 15 days, and I will raise any cancellation, refund or billing concern with finance@nexgenplacement.com first.
I agree to bear the applicable card processing fees on this payment.
If Stripe or Nexgen Placement LLC needs more proof or documents for this transaction, I will provide them.
Signature
*
Signature
Submit
