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Credit Card/Debit Card Authorization Form

Zhang & Associates, P.C.

Please fill the necessary information in the form below. Please then print the form and send it to our offices via either one of the following methods: 1) fax, 2) scan, or 3) physically mail the form to our office at the address listed below. If you are faxing this form, please be sure to either call your in-charge Attorney or clerk so that they may be notified of the incoming transaction.

Attn: Accounts Receivable
Zhang & Associates, P.C.
9999 Bellaire Blvd, Suite 920
Houston, TX 77036
Tel: (713)771-8433
Fax: (713)771-8368

Card Holder Information:

First Name:

  Middle Initial:   Last Name:

Address 1:

Address 2:

City:

  State:   Zip Code:

Daytime Phone:

  Evening Phone:

Credit Card Information:

Name on Credit Card:

Credit Card/Debit Card Type:

Visa Master Discover

Credit Card/Debit Card Number:

Expiration Date(mm/yy):

    Security Code:

The last three digit security code is the 3 digit number on the back for your card. The code is located in the signature line and is usually the last three numbers directly after your card number. (Some cards do not have the card number listed, so in this case the Code is the last 3 numbers.)

Authorized Amount:

  Case type:

Client Name:

  Date(mm/dd/yy):

Card Holder Signature:   _________________________