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
