Credit Card Authorization Form

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Offices in: Bakersfield | Los Angeles | Palm Desert | San Jose
Corporate Office: 1731 16
Street, Ste. H, Bakersfield, CA 93301
th
Tel (888) 514-5067 | Fax (888) 247-1288
Credit Card Authorization Form
* FAX COMPLETED FORM TO ACCOUNTING @ (661) 377-1026 *
Schmidt – Barger, Inc., dba Attorney’s Certified Services is authorized to charge your card for the amount of the charges incurred to
complete the Order(s) submitted, as described in either your letter of instruction or other means, including this authorization.
On this date(s) ______ / ______ / ______
Invoice Number ___________________
For Ongoing Charges
One Time Charge
Dollar Amount $___________________
Cardholders Name: __________________________________________________
Business Name: ____________________________________________________
Address Associated: _________________________________________________
_________________________________________________
Telephone: __________________________ Fax: __________________________
Email Address: _____________________________________________________
ACS Account Number: _______________________________________________
Check one:
VISA
MASTERCARD
DISCOVER
AMEX
Card #: ___________________________________________________________
3 or 4 Digit #: _________ Billing Zip Code: __________ Exp. Date: ___ / ___
I certify that I am the holder of the above credit card, or have been authorized by the holder, to use it to pay for services provided by Attorney’s Certified Services, Inc. and I agree
to all of the terms and conditions.
Signature: ______________________________ Date: ______ / ______ / ______
This Authorization form is required for new clients and clients outside of California. For Clients in California, your first Order is always charged to a credit
card. For clients outside California, all Orders will be charged to your card, unless prepaid by check. Once credit has been established, this authorization is
a guarantee of payment. Attorney’s Certified Services, Inc. reserves the right to charge your card for past due balances not paid within our credit terms.
Because most of these transactions are performed electronically, it is not required that Attorney’s Certified Services, Inc. keep a physical credit card on file
in order for the charge to the card to be valid. I UNDERSTAND THE CHARGE FOR THE ABOVE SERVICE IS NON-REFUNDABLE, NON-REVOCABLE,
AND NON-CONTESTABLE. I WAIVE MY RIGHT OF REFUND AND/OR TO DISPUTE THE CHARGE.
Attorney’s Certified Services, Inc. reserves the right to restrict the credit of any client for any reason.
It is further agreed that this contract is negotiated in Bakersfield, CA.
creditcardauthorizationform2014.wrd

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