Fillable Credit Card Authorization Form printable pdf download

Credit Card Authorization Form

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Oregon State Bar Credit Card Authorization Form

DO NOT USE FOR: Annual Membership Fees, Section Membership Dues, or Lawyer Referral Invoices

Purpose of Payment

Reinstatement Fees

Amt:________ Acct No: 115-4580-000

Status Change Fees

Amt ________ Acct No: 100-2510-035

Certificate of Good Standing

New Lawyer Mentoring Fee

Acct No. 116-4565-000

Invoice Payment - Invoice #_________________________________________

MCLE Fees

$ _________ MCLE Sponsor Fee (MCLE Reg. 4.350)

Acct No. 121-4550-000

Program Title _______________________________

Date

_____________________

Program Title _______________________________

Date

_____________________

$_________ MCLE Sponsor Late Fee (MCLE Reg. 4.350)

Acct No. 121-4355-045

(for applications received more than 30 days after program date)

$ _________ MCLE Member Late Filing Fee (MCLE Rule 7.5)

Acct No. 121-4355-000

Other (describe)___________________________________________________________________________

$__________________

Acct No. ________-________-________

CLE Exhibitor/Sponsor Fee: Exhibitor/Sponsor Name____________________________________________________

Program Title _________________________________________

Date

_____________________

The bar only accepts VISA and MASTERCARD

Cardholder authorizes the Oregon State Bar to charge his/her: Visa

MasterCard

for this transaction.

6-Digit Bar or Non-Member Number: ______________________________________________

Cardholder Name: __________________________________ ________Authorized Charge Amount $________________

Cardholder Signature: ________________________________________________________________________________

Required if member completes form

Credit Card Number: ________________________________________________Expiration Date: ___________________

Credit card address is the address to which the credit card statement is billed each month.

Credit Card Street Address: ___________________________________________________________________________

Credit Card City/State/Zip Code: _______________________________________________________________________

Obtain a phone number or email address for confirmation. If an email address is provided, a receipt will be sent when the

card is charged and approved.

Phone No: __________________________________ E-mail Address: __________________________________________

Completed by__________________________________________________________Date ________________________

Credit Card Authorization Form

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