• Authorization for Credit Card Use

    Authorization for Credit Card Use

  • 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

  • Clear
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  • Should be Empty: