CREDIT CARD AUTHORIZATION FORM
NOTE : Please note that this is not an automated payment system. We will not charge your credit card until you have had a consult with one of our attorneys.
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BY COMPLETING AND SENDING THIS AUTHORIZATION FORM TO US, YOU HEREBY ACKNOWLEDGE, AGREE AND AUTHORIZE NATOLI-LAPIN, LLC, OR ANY OF ITS ASSOCIATES TO CHARGE THE APPROPRIATE SERVICE FEES TO YOUR CREDIT CARD OR DEBIT ACCOUNT.
Name (As it appears on the card): *
Card Number: *
Type of Credit Card: *
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Expiration Date: *
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CVC - Security Code: *
Billing Address: *
Street Address (Line 1): *
Street Address (Line 2):
Apartment or Suite Number:
City: *
State: *
Zip Code: *
Authorization:
E-Sign Name: *
