Authorization for Credit Card Use

Authorization for Credit Card Use
Name on Card*
Billing Address*
Billing Address Continued*
Visa
Mastercard
Discover
Am Ex
Credit Card Number*
Expiration Date*
(last 3 digits located on the back of the credit card)*
I authorize River City Integrative Counseling to charge the amount listed in the schedule of fees to the credit card provided herein. I agree to pay for this purchase in accordance with the issuing bank cardholder agreement.
Cardholder – Please Sign and Date
RCIC Alcohol and Drug Program 2/16/22
Signature*

Clear
Date*
Name*

First NameLast Name
Should be Empty: