Card Remote | H20life Solutions

Secure Credit Card Authorization Form

Secure

Important Notice

This page is used solely to authorize a manual credit card charge by our office. No payments are processed on this page.

Your information is transmitted securely and will only be accessible to authorized H2O Life Solutions personnel. Your card data will be permanently deleted after payment is processed.

Customer Information

Full Name*

Email Address*

Phone Number*

Installation Property

Installation Address*

City*

State*

ZIP*

Product / Service

Product

Whole Home City Water Purification System with Alkaline Reverse Osmosis

Premium whole-home water treatment system including alkaline reverse osmosis drinking water system.

Amount to Charge*

Amount$0.00

4% Credit Card Processing Fee+ $0.00

Total to Charge$0.00

Credit Card Information

Your card information is transmitted securely. We never store your full card number after payment is processed.

Cardholder Name*

Card Type*

Card Number*

Exp Month*

Exp Year*

CVV*

Card Photos

Please upload clear photos of the front and back of the credit card being used.

Credit Card — Front

Click to upload

JPG, PNG, PDF accepted

Credit Card — Back

Click to upload

JPG, PNG, PDF accepted

Photo Identification

Please upload a clear photo of your government-issued ID.

Driver License / ID — Front

Click to upload

JPG, PNG, PDF accepted

Driver License / ID — Back

Click to upload

JPG, PNG, PDF accepted

Digital Signature

Please sign below using your finger or mouse.

Sign here

I authorize H2O Life Solutions to charge the card provided above for the amount listed on this authorization.

Your information is encrypted and transmitted securely.