CC Auth Payment

AUTHORIZATION FOR CREDIT CARD USE

TO:

OF:

INVOICE #*

TOTAL CHARGES

AS OF DATE

You have requested to pay the above stated charges by credit card. Please complete this form and use the submit button below to complete the payment. If you have any questions please contact our office. (661) 589-3870

TYPED/PRINTED NAME*

Print Full Name

Consent

I agree to pay the above stated charges by credit card.

I as registered "TYPED/PRINTED NAME" and/or legal, and/or agent thereof, authorize the charges stated above to be charged to the following credit card account. I certify that I am a person who is authorized to use this credit card.

SELECT PAYMENT TYPE*

VISA
MASTERCARD
AMERICAN EXPRESS
DISCOVER

CARD NUMBER*

EXPIRATION DATE*

MM/YR

CCV*

SECURITY CODE

CC BILLING ADDRESS*

Street Address City State ZIP Code

NAME ON CARD*

Signature*

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