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If you are paying with a credit card please note the following information must be provided in order for us to accept your credit card payment:

  1. We need a legible copy of your driver license if you still have it.  If you do not have a driver license i.e. the police took it away from you during the DUI investigation, please provide a copy of some other form of ID.

  2. We need a legible copy of the credit card you are intending to use front and back. 

  3. We need the form below filled out completely, signed and faxed or emailed back to us.

  4. For your convenience the form below is available in the following formats:

MSWord Format, click here,    WordPerfect format, click here,   Simple Text format, click here

or

Print out this page, fill it out completely and fax it back to us at

1-520-620-0818

 

 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

 

 

Copyright ©  2006 Darby Law Office

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