Credit Card Authorization

Phone: 855-768-5283 | Email Address: sales@premierlegalsupportservice.com

To: Premier Legal Support Service
1609 James M Wood Blvd
Los Angeles, CA 90015

Date (required):

Invoice No. (required):

Subject of Request (required):

Received (required):

Approval No. (required):

From:

Your Name (required):

Email Address (required):

Company Name (required):

Credit Card Billing Address (required):

City (required):

State: (required)

Zip (required):

Home Phone (required):

Work Phone (required):

By this Memo, I authorize Nationwide Legal, LLC to be paid for the transaction of the above referenced company in the amount of $ by using the Credit Card listed below.

 Mastercard Visa American Express Discover

Credit Card Number (required):

Expiration Date (required):

Exact Name As It Appears On The Card (required):

3 or 4 Digit Card Code (required):

I understand the charge for the above service is non-refundable, non-revocable, and noncontestable. I waive my right of refund and/or to dispute the charge.

Authorized Signature of Credit Card Holder (required):

Date (required):

Enter Security Code:
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