Credit/Debit Card Payment
Consent Form
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Client Name ____________________________________________________
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Print Last
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First
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Middle Initial
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Name on
Card if different ___________________________________________
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I authorize ___Jill Vermeire/Red Lotus Way,
Inc._ and ProfessionalCharges.com
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Service Provider Name
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to charge my card for professional services for
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the amount of $_______ (plus $8 usage charge)_=__________.
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Type of Card: VISA MasterCard.Discover  Exp. Date
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Card Number _______ - _______ - _______ - _______
DVV Number ______
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Card Holder's Billing Address for Monthly Card Statements
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___________________________________________________________________
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Street
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City
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State
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Zip
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Card Holder Signature ____________________________ Date ____ /____
/____
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Charges
will appear on your card statement as ProfessionalCharges.com
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