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Credit Card Authorization


Complete only if paying by credit card. This must be signed by the person whose credit card has been used, whether yourself or some other person.

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 Address_________________________________________

Print Card Holder City, State and Zip__________________________________

Print Card Holder Telephone_______________________


 


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