Credit Card Authorization Form |
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Contact Information
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Attorney’s name
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Client’s name
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Street Address:
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City, State, ZIP:
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Phone Number:
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Fax Number:
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Email Address:
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Please complete for credit cards transactions
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Card Type (X one):
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VISA
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MasterCard
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AmEx
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Discover
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Card Number:
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Card Security Code (the 3 or 4-digit code on the back of card or the front of the AMEX):
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Card Expiration:
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Name On The Card as it Appears:
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Billing Address:
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Amount Due: Depending on Service Requested:
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2.5% surcharge is added to all credit card charges | Please fax this form to 815-717-7468
Signature of credit card holder for authorization
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