9455 MAGNOLIA AVENUE RIVERSIDE, CA 92503 (951) 353-8281  FAX (951) 353-8286 accounting@boscolegal.org www.BoscoLegal.org

CREDIT CARD BILLING AUTHORIZATION FORM

NAME APPEARING ON CARD:

CREDIT CARD BILLING ADDRESS:

TELEPHONE NUMBER:

FAX NUMBER:

CREDIT CARD TYPE:

VISA  /  MASTERCARD  /  DISCOVER

CREDIT CARD NUMBER:

CVV2 CODE:

EXPIRATION DATE:

CARDHOLDER SIGNATURE:

DATE:

I HEREBY AUTHORIZE BOSCO LEGAL SERVICES, INC., TO PLACE THE CHARGES INDICATED BELOW ON MY CREDIT CARD AS A TELEPHONE / FAX TRANSACTION:

AMOUNT AUTHORIZED:

This Authorization form is required for new clients and clients outside of California. For Clients in California, your first Order is always charged to a credit card. For clients outside California, all Orders will be charged to your card, unless prepaid by check. Once credit has been established, this authorization is a guarantee of payment. Bosco Legal Services, Inc. reserves the right to charge your card for past due balances not paid within our credit terms. Because most of these transactions are performed electronically, it is not required that Bosco Legal Services, Inc. keep a physical credit card on file in order for the charge to the card to be valid. I UNDERSTAND THE CHARGE FOR THE ABOVE SERVICE IS NON-REFUNDABLE, NON-REVOCABLE, AND NON-CONTESTABLE. I WAIVE MY RIGHT OF REFUND AND/OR TO DISPUTE THE CHARGE. Bosco Legal Services, Inc. is authorized to charge your card for the amount of the charges incurred to complete the Order(s) submitted, as described in either your letter of instruction or other means, including this authorization.

Bosco Legal Services, Inc. reserves the right to restrict the credit of any client for any reason. It is further agreed that this contract is negotiated in Riverside, CA.

I certify that I am the holder of the above credit card, or have been authorized by the holder, to use it to pay for services provided by Bosco Legal Services, Inc. and I agree to all of the above terms and conditions.