Authorization To Charge Credit Card Form printable pdf download

Authorization to Charge Credit Card

Client’s Name __________________________

I, ____________________________________, hereby authorize the Richardson Law Firm, P.L.L.C. Attorneys at Law, to

charge my credit card for a total of $___________ (Optional: Plus $__________ for fines and court costs)

MasterCard

Visa/Visa Check/Visa Debi

Discover

TYPE OF CARD:

CARD NO.:

EXPIRATION DATE:

NAME ON CARD: __________________________________________________________

BILLING ADDRESS ON CARD: ______________________________________________

______________________________________________

Verification No. (3 digit number on back of card):

__________

Telephone no. ____________________

I have enclosed a photocopy of the front and back of my driver’s license. I understand that the attorney shall have

no obligation to render any services in this matter until the firm receives the original of this completed document in the

mail, and my card is charged. I agree to pay the charge shown hereon, according to my cardholder agreement.

Cardholder Signature: _______________________________________________________________________________

Printed Name: ____________________________________________________________________________________

Date: ___________________________________________________________________________________________

PLEASE REMEMBER TO ENCLOSE A PHOTOCOPY OF YOUR DRIVER’S LICENSE

After completion please return to Richardson Law Firm, PLLC, 2310 S. Miami Blvd, Suite 134, Durham NC 27703.

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