Credit Card Authorization - Fax
This authorization is to be used in conjunction with our previously transmitted enrollment form
Enrollment Date  
 Agency Name  
 Email Address  
Current Charge Authorized: $39 Set up +  Monthly fee = Amount Due
Credit Card  Visa   AmEx   MasterCard
 Name as it appears on credit card
 Credit Card Number   Exp Date mm/yy
Amount: (Enter amount before faxing)
 Authorized by: X ______________________________________________ Please sign before faxing
This fax page does not transmit electronically!
Complete the information -
Print and fax this page to: 1-410-363-8218
to:, Inc.
8 Greenspring Valley Rd.
Owings Mills, MD 21117



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© Gordon K. Harden, Jr. 1996-2004
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Page Created 5-1-98
Revised 4-12-2004