CC Authorization Safe Harbor Counseling Credit Card Payment Authorization Form Client Name(Required)Date(Required) Please initial(Required) I hereby authorize Safe Harbor Counseling to charge the amount I indicate using the credit card information below. Please initial(Required) I understand that I will be notified of any charges made by Safe Harbor Counseling to this credit card. Please initial(Required) I understand that I can leave a message on with Beth Plachetka, LCSW, EdD (630-272-4959) authorizing payment. Please initial(Required) I will state the client name, amount to be charged (from bill) and to use the credit card on file. All four options must be checked to express your approval.Cardholder Name(Required)Account Type(Required) VISA MasterCard Discover Amex Credit card number(Required)Exp Date (MM/YYYY)(Required)CCV(3/4 Digit # on back of card)(Required)Billing Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email(Required) Phone(Required)Authorization(Required) I authorize Safe Harbor Counseling to charge the credit card indicated in this authorization form according to the terms outlined above. If Safe Harbor Counseling is unable to process my payment I will be responsible for an alternate payment arrangement and a $10.00 fee in addition to any other fees that may be applied though the credit card company. Authorization(Required) I certify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form. Signature(Required)Date(Required)
