Credit Card Payment Form
Firm Name:
Firm Address:
Completed By:
Phone Number:
Email Address:
Name on Credit Card:
Card Type:
Credit Card Number:
Expiration Date:
Card Security Code:
Service For:
Total Fee:
(include fax/email service fee and a 5% processing fee).
By signing this form I certify that I have authorization to
pay with the credit card above and I authorize Action
Process Service to charge th
is
credit card
for the total
service fee
(including the fax/email service fee and a 5%
processing fee for all charges)
. I
understand that
if I miss
calculate the total fee above that the charges will be
applied as indicated without notice. I further understand
that
if the service is cancelled for any reason at all after I
submit this payment that there will be no refunds.
Type Your Name Above
Type Todays Date Above