credit card billing authorization form
(please
print this form, fill it out and fax it to TPA at 818-610-7422)
billing information
name:
____________________________________________________________________________________
(as it appears on the credit card)
address:
__________________________________________________________________________________
(where the statement for this card is delivered)
city: ______________________________________ state: __________________ zip code: _______________
credit
card: ___ 
___ 
___ 
___ 
(please
check one)
credit card number: ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___
expiration date: ___ ___ / ___ ___ last three digits in the signature strip on back: ___ ___ ___
front four digits on American Express Cards ___ ___ ___ ___
cardholder signature: _________________________________________________ date: ________________
