Credit Card Authorization - Joseph & Smargiassi, LLC

Name

First

Last

Email

Phone

of for Manual

Card Number

Expiration (MMYY)

Name on Card

Billing Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Amount to be Charged (USD)

Frequency of Charge

Manual Entry for Payment

I am an authorized user on this account and authorize Joseph & Smargiassi, LLC to manually enter the account information provided on this form. I understand that I could present my card in person, but elect to submit this form instead.

Acknowledgments

I AGREE THAT THIS FORM MAY BE SIGNED ELECTRONICALLY. MY ELECTRONIC SIGNATURE APPEARING ON THIS DOCUMENT IS THE SAME AS A HANDWRITTEN SIGNATURE FOR THE PURPOSES OF VALIDITY, ENFORCEABILITY AND ADMISSIBILITY. I UNDERSTAND THAT SUBMISSION OF THIS FORM IS NOT THE SAME AS A SUCCESSFUL CHARGE TO MY CREDIT OR DEBIT CARD ACCOUNT. MY ACCOUNT WITH JOSEPH & SMARGIASSI, LLC WILL REFLECT THIS AS A PAYMENT ONLY WHEN THE CHARGE IS SUCCESSFULLY PROCESSED.

Digital Signature

First

Last

Date of Authorization