You can now pay your outstanding invoice _____________ by credit card.  Kindly complete the following and return it via fax to Office Manager.  If you have any questions, please call the Office Manager at [Firm Name], [Firm Telephone Number].

I hereby authorize [Firm Name] to charge $___________ to

›  Visa             ›  MasterCard             ›  AMEX          ›  Diners

Card Number: ______________________                Expiration Date: ____________

Name as it appears on card: _______________________

Billing Address for Credit Card:__________________________________

Zip Code:_______________

Signature: _____________________________________

Date: ________________