Gateway Recovery Center II LLC

Secure Payment Form

Guest Name or Number (required)
Email Address (required)
Phone Number
Additonal Information
Cardholder Name (required)
Cardholder Address
Cardholder City
Cardholder State
Cardholder Zip (required)
Card Number
Card Expiration Date
Payment Acknowledgement

I hereby authorize Gateway Recovery Center II, LLC to charge my debit/credit card indicated below for the Minimum Service Fee, Service Fee, any due and owing late payments or other charges, as applicable, and as provided in this Agreement. I understand that this authorization shall remain in effect until I notify Gateway Recovery Center II, LLC of any changes in my account information or termination of this authorization. If, at any time, updated debit/credit card information is provided to Gateway Recovery Center II, LLC over the phone, verbal authorization to charge the updated card shall be deemed given. I certify that I am an authorized user of this debit/credit card and will not dispute with my bank or debit/credit card company transactions done in accordance with this Agreement.