Credit Card Payment By Fax

Credit Card Authorization (by fax)

Credit Card Payment by fax

Please complete all fields.  You may cancel this authorization at any time by emailing 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 not to exceed $____________.

I would like my credit card information to be saved to file for future transactions on my account.

__________________________________________  _________________________________

Customer Signature                                                                                   Date

Please print, fill out and fax to (01) 415-462-0688.

Thank you,

Filley and Associates

Filley and Associates Payment Page