Credit Card Authorization Form - Tulsa Counseling Services

Client Name*

Card Number*

Card Expiration Date*

Card Security Code*

(Mastercard & Visa: 3 digits on back of card; Amex: 4 digits on front of card)

Name as it appears on the credit card*

CardholdersAddress*

Street Address Address Line 2 City State ZIP Code

Consent*

I the cardholder, authorize Jacquyn R. Cleary, MS, LPC, LMFT/Cleary Counseling and Consultation Inc to process charges to the credit card listed above for my monetary obligation solely related to my treatment with Jacquyn R. Cleary/ Clearly Counseling and Consultation Inc.

Cardholder's Signature*