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.
Billing Address: __________________________________________
Where you receive you credit card statement
City, State, Zip: ___________________________________________
Telephone: (_______) ______________________________________
Fax or email this completed form to Law Office of David Alan Darby
Direct Fax: (520) 620-0818 Email: email@example.com