Credit Card Payment Form


Credit Card Payment Form
Please complete the following information
Account Number _______________________
Company Name ________________________________________________________________________
Card Issuer
American Express
Name on Card ________________________________________________________________________
Card Number ________________________________________________________________________
Expiration Month / Year ____________________________
Security Code ___________________
Card Billing Address ___________________________________________________________________
City _____________________________________________
State ________________________
Postal Code ___________________
Check here if this is an update to your billing address
By my signature, I authorize DAT to charge my credit card & account number listed above. I under-
stand payment for my current invoice will be charged to my crredit card at the time of billing. I further
authorize the above listed credit card company to accept this letter in lieu of my signature.
Signature ______________________________________________________________________________
(Please print) Name ___________________________________________________________________
Date ________________
Phone Number ________________________________________
Please fax this completed form to DAT, Billing Services Department 1-800-328-5316
PO Box 23519 | Portland, OR 97281-3519 | 8405 SW Nimbus Avenue | Beaverton, OR 97008
Telephone 1-800-547-5417 | Fax 1-800-328-5316


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Parent category: Financial