Chris Loomis Consultations

~A Private Investigations Firm~

Credit Card Authorization Form

This Form May Be Faxed via (626) 407-4495 or E-Mailed via Chris@clcpi.com to Our Arcadia, CA Office
Please Print

or Type Clearly MasterCard American Express Discover

Expiration Date
Month

VISA

Bank Phone Number on Back of Card Credit Card Number

/
Year

Security Code
VISA & MasterCard: CVV2 Number American Express: Discover: CVC2 Number CID Number (last 3 digits on reverse of card inside signature panel) (4 digits on right-front of the card above last 4 digits of card number) (3 digits on back of card to the right, and above of the signature line)

For security and authorization purposes, we require the cardholder to furnish the mailing address to which the Credit Card Company mails the monthly statement. Credit Card Billing Address:

Address

City / State / Zip Code

Card Holder's Name (Individual) on Credit Card Name of Company, Organization or Governmental (federal, state, county or city) Entity Printed on Front of Credit Card (if any)
Please Print Name Exactly As It Appears On Credit Card

I authorize Chris Loomis Consultations to charge my Credit Card for current and/or future purchases of their services and to verify the Credit Card Billing Address of my Credit Card with the issuing bank or other financial institution upon my signature. In lieu of a credit card imprint, I hereby agree that if I order Services from Chris Loomis Consultations I will honor the charges. I agree that if the credit card company refuses to pay Chris Loomis Consultations for such charges incurred, the undersigned shall be responsible for the payment of such charges. I further agree not to dispute any charges to my credit card for Services properly rendered and/or provided by Chris Loomis Consultations. I certify that all information disclosed above is complete and accurate and that all information being requested from Chris Loomis Consultations is for legal, legitimate business purposes only. I also declare that I shall not willfully and/or knowingly take any action, directly or indirectly which will cause Chris Loomis Consultations to be in violation of any law. I also affirm under penalty of law that I am the authorized representative of the above listed company, organization or governmental (federal, state, county or city) entity. I certify that all information disclosed above is complete, true and accurate. Signature of Card Holder or Authorized Agent Print Name of Cardholder or Authorized Agent Date Signed

THANK YOU FOR YOUR PATRONAGE!

Your personal information will not be shared with any other third parties, except as necessary for the express purpose of payment processing for your purchases made from Chris Loomis Consultations unless required to do so by law or regulatory authority. Your nonpublic personal information provided on this form will not be sold or supplied to any other company, individual or group.