Credit Card Authorization

PLEASE READ: This is a payment authorization form. Your card will not be charged by submitting this form. Payment will be processed as you were advised. Normally when fieldwork is complete. If you have any questions please call the office directly at (305) 767-6802.

Credit Card Authorization Form

Your Name *

Phone Number *

Amount to be Processed *

Name (As it appears on credit/debit card) *

Card Type *

Card Number *

Expiration Date *

Security Code (for AMEX front of card) *

Billing Zip Code *

Email Address *

By submitting this form you are confirming that you are the authorized card holder or representative. I agree to pay the above charges according to the card issuer's agreement. I understand that submission of this form will serve as my authorization on the credit charge slip and as a signature on file for all authorized charges and outstanding balances now, and in the future. I UNDERSTAND THAT USING A CREDIT CARD FRAUDULENTLY IS ILLEGAL AND CHARGES WILL BE PURSUED TO THE FULL EXTENT OF THE LAW.

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