Professional Charges Forms

	Your debit or credit card has been charged for professional services provided to you as follows: Type of Card:VISA, MasterCard or.Discover
	Date of Service ___________		_____________________________
			Card Holder Name
	Type of Service __________________

	Total Charged $___________		_____________________________
			Authorized User, if different
	Services Provided by:

	Name ___________________________		_____________________________
			Card Number
	Address _________________________

	________________________________		______________
			Expiration Date
	________________________________

	Phone ___________________		____________________________
			Date Charge was Submitted, if
			different than Date of Service.
	Notice:
	These charges will appear on your monthly card statement as
	ProfessionalCharges.com or some abbreviated form of it,
	and not the name of your provider or the services rendered.