Credit Card Authorization - Fax
This authorization is to be used in conjunction with our previously transmitted enrollment form
39 Set up +
Name as it appears on credit card
Credit Card Number
Exp Date mm/yy
(Enter amount before faxing)
______________________________________________ Please sign before faxing
This fax page does not transmit electronically!
Complete the information -
Print and fax this page to: 1-410-363-8218
8 Greenspring Valley Rd.
Owings Mills, MD 21117
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© Gordon K. Harden, Jr. 1996-2004
Page Created 5-1-98