Credit Card Payment Form

Credit Card Authorization

Please complete all fields.  You may cancel this authorization at any time by emailing us. This authorization will remain in effect for this case.  This form will be shredded.

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 send a pdf or photo of the form to

Thank you,

Filley and Associates

Filley and Associates Payment Page