Select the following text and send it to your printer, then Mail or Fax to:
JAMES R. SPIEVAK, APC, 600 WEST BROADWAY, SUITE 1150, SAN DIEGO, CA 92101, Office (619) 236-1820, Fax (619) 236-1536
Client Credit Card Pre-Authorization
In an effort to better serve our clients and simplify your billing experience, our firm offers MASTERCARD and VISA acceptance. Charge card information is filed with your confidential client information and kept secure.
1. SELECT PAYMENT OPTION:
______ (initial) I hereby authorize James R. Spievak, a Professional Corporation to charge $_______________________________ on the balance currently due on my account or as a deposit for fees and costs to be incurred, OR
______ (initial) I hereby authorize James R. Spievak, a Professional Corporation to charge the balance of my account automatically each month. My card will be charged the FIRST of the each month for fees and costs billed in the current billing.
2. PAYMENT INFORMATION:
Client Name:______________________________________________________________________________________________
Client Billing Address:_______________________________________________________________________________________
Mark one: Mastercard: _____ OR Visa: _____
Card Number:____________________________________________ Expiration Date:_______________ Security Code:_________
The undersigned guarantees performance of the financial provisions of this agreement.
Card Holder Name:_________________________________________ Card Holder Signature:_____________________________
Date:________________________
CHARGE POLICY: Being the cardholder or the Corporate Officer, by signing above I understand and agree to the terms set forth in this agreement, agree to pay, and specifically authorize charging my credit card for the services provided. I further agree that in the event my credit card becomes invalid, I will provide a new valid credit card upon request, to be charged for the payment of any outstanding balances owed including any service fees or late fees. I furthermore confirm that I have received all services. Charges made for actual services performed by our office are non-refundable. In the event of pre-payment any unused funds will be refunded within 30 days. THANK YOU!
