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 Name Last Name
Should be Empty: