Client Name: If not the person identified below.
First
Init.
Last
Jr/Sr.
Type:
Number: Use credit card on file
(We will contact you if necessary)
Exp. Date:
Amount in Engagement Letter
Amount of prior month invoice
Amount of open invoices
Amount specifically requested in correspondence
Specific Amount
Email (for confirmation):
You are required to electronically sign this form
by typing in your name preceded by /s/
e.g. /s/ John Doe
By clicking the I Agree button, you are agreeing to
pay the amount above by the credit card identified.
You should print this page for your records.
