Credit Card Authorization

Auto Accident Pain Relief Center of Illinois

Client Name

Cardholder Name

Billing Address

Card Type

Visa Mastercard American Express Discover

Credit Card Number

Expiration Date

Card Indentification Number (last 3 digits located on the back of credit card)

AMOUNT $

Biweekly Invoice One-Time Payment

I authorize ( ) to charge my credit card provided herein. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement.

Cardholder - Print Name, Sign, and Date Below:

Signed:

Dated:

Name

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