Credit Card Authorization
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To: Internet Legal Referral or Agent________________________________________ I/we have authorized you to charge the sum of $________ To credit card #_________________________________ Exp. date____ for ____Legal Referral Services____________________________ Signature of credit card holder ______________________________
Print Card Holder Name_____________________________________________________
Print Card Holder
Print Card Holder City, State and Zip__________________________________
Print Card Holder Telephone_______________________
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