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Get Credit Card Payment Authorization Form

Om ACCOUNT INFORMATION Clien t Name : Company: Please apply this payment to: Re tainer on Acc ount, or KEG B Invoice Number(s) : AUTH ORIZATION I hereb y authorize KIRBY EADES GALE BAKER to debit my Credi t Card identified below: in the amount of $ CD N U.S.* *U.S. paymen t only accepted for VISA or Mas terCa rd S igned : Date: CREDIT C ARD INFORMATI ON Cr.

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