| LAW OFFICE OF DAVID ALAN DARBY P.O. Box 12427 Tucson, Arizona 85732 CREDIT CARD CHARGE AUTHORIZATION AGREEMENT I, _______________________________, the holder of the following credit card (check one, please): VISA ___ MasterCard ___ Amex ___ Discover ___ Card Number: ___________________________ Exp.Date ____/____ with a three digit security code ______ on the back of the card, hereby authorize The Law Office of David Alan Darby, in Tucson, Arizona to charge my credit card in the amount of: $___________________________________________________ for attorney’s fees for legal representation for _________________. I further authorize the Law Office of David Alan Darby to charge my credit card each month beginning the ______ day of __________, 2003 in the amount of $____________ each month, for the period of ____ months for attorney’s fees for continued legal representation. Cardholder: ______________________________________________ Signature: _______________________________________________ Company: _______________________________________________ Billing Address: __________________________________________ Where you receive you credit card statement City, State, Zip: ___________________________________________ Telephone: (_______) ______________________________________ Date: __________________________________________________ Fax or email this completed form to Law Office of David Alan Darby Direct Fax: (520) 620-0818 Email: david@arizona-dui-defense.com | 