Credit/Debit Card
Payment
Consent Form
|
 |
| Client
Name ____________________________________________________ |
|
. |
Print Last
|
First
|
Middle Initial
|
|
|
|
Name
on Card if different ___________________________________________ |
|
.
|
| I
authorize
___________________________ and ProfessionalCharges.com |
| . |
Service
Provider
Name |
| to
charge my card for professional services for |
|
|
|
|
the amount of $__________________. |
|
Type
of Card: VISA
MasterCard.Discover
Exp. Date __________ |
| . |
| Card Number _______ -
_______ - _______ - _______ DVV Number ______ |
| . |
| Card
Holder's Billing Address for Monthly Card Statements |
| |
| ___________________________________________________________________ |
| Street |
City |
State |
Zip |
| . |
| Card
Holder Signature
____________________________ Date
____ /____ /____ |
|
|
|
Charges
will appear on your card statement as ProfessionalCharges.com
|
