Credit Card Fax Payment

Credit Card Authorization (by fax)

Credit Card Authorization (by fax)

Please complete all fields.  You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

Card Type:   ☐ MasterCard  ☐ VISA  ☐ Discover  ☐ AMEX

Cardholder Name (as shown on card): ____________________________________________

Card Number:  ______________________________________________________________

Expiration Date (mm/yy):  _______________________________

Security Code:  ________________

I, ____________________________________, authorize Filley and Associates to charge my credit card above for agreed upon purchases.  I understand that my information will be saved to file for future transactions on my account.

 

__________________________________________  _________________________________

Customer Signature                                                                                   Date

Please print, fill out and fax to (01) 415-462-0688.  Please call (01) 415-462-1631 to confirm before faxing.