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Dutton & Casey Credit or Debit Card Authorization Form

Dutton & Casey Credit/Debit Card Authorization for First Meeting

(Address where monthly credit card statements are received)

Amount: $ 350.00 (first meeting fee)

(Associated with credit card)

Being the cardholder, by submitting this form I understand and agree to the terms set forth in this agreement, agree to pay, and specifically authorize Dutton & Casey, PC to charge my credit card or debit card, for the services provided. I further agree that in the event my card becomes invalid, I will provide Dutton & Casey, PC with a new valid card upon request and/or a bank cashier’s check for the payment of any outstanding balances owed to Dutton & Casey, PC.