|
|
|
|
IMPORTANT:
|
|
|
- Please have your CPLS File No. from your statement available before making a payment.
- Payments processed after 6:00 p.m., and on weekends, will not be posted until the following business day.
- By completing this form, you are authorizing CPLS to use this card to pay for the legal services being provided to you, person, and/or business entity listed in the Client Name field of this payment form.
- All payment amounts are processed in U.S. dollars.
|
|
|
Payment Information:
|
| Payment Date:
|
03/05/21
|
|
*Client Name:
|
|
|
*Client Type:
|
|
|
*File Number:
|
(Enter the number exactly as it appears on your invoice including dashes _ _ _ _ - _ )
|
| Invoice Number.:
|
|
|
*Payment Amount:
|
|
|
Charge Amount:
|
|
|
Credit Card Information:
|
|
*Card Type:
|
|
|
*Card Number:
|
|
|
*Card Expiration
Date:
|
MMYY
|
*Card ID (CVV2/CID) Number:
[What is the Card
ID?] |
|
*Cardholder Name
(Name as it appears on card):
|
|
| *Card Billing Address:
|
|
| *Card Billing City: |
|
| *Card Billing State: |
|
| *Card Billing Zipcode: |
|
| *Email Invoice To: |
|
| |
|
*I agree to the Terms and Conditions:
|
By submitting this form, you hereby authorizes CPLS, P.A. to charge against said card the following one time charge for legal services and/or costs provided to and/or on behalf of the above client. Your agreement to pay the Client’s fees and costs does not authorize CPLS, P.A. to disclose any information to him/her about the Client without the Client’s approval. |
|
|
|
THE CENTER FOR PROFESSIONAL LEGAL SERVICES
201 E. Pine Street, Suite 445, Orlando, FL 32801 407.647.7887 Tel. 407.647.7887 Fax
www.cplspa.com
|
|