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Single Transaction Credit Card Authorization Form - Colorado

Single Transaction Credit Card Authorization Form Form. This is a Colorado form and can be used in Civil District Court Federal .
 Fillable pdf Last Modified 5/17/2012
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UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLORADO 901 19th Street, Room A105 Denver, Colorado 802943589 3033352050 Fax: 3033352040 SINGLE TRANSACTION CREDIT CARD AUTHORIZATION FORM (NOTE: THIS FORM CANNOT BE USED FOR FUTURE CHARGES. A NEW CREDIT CARD AUTHORIZATION FORM MUST BE COMPLETED FOR EACH CHARGE.) This credit card authorization form can be used to pay the court's bar application fee, pay a filing fee for a submission of a sealed case or miscellaneous matter, or miscellaneous fees. Please check the appropriate check box: Bar membership application fee(s) for: Attorney name: Attorney name: Attorney name: Filing fee(s) for a sealed case or miscellaneous matter Case title: Miscellaneous fee for Please Print Credit Card Information: Full Name on Card: ____________________________________________________________________ Billing address: _______________________________________________________________________ City _____________________________ State: ___ Zip Code: ____________ Phone Number: ____________________ Type of Card: ________________ Card #: _______________________________________________ Exp. Date: ___________ VCODE (3 or 4 digit # on back of card) ______________ I hereby authorize the use of this credit card for a onetime charge for the payment noted above. The information will not be used for any other charges. Date: Approved by: ______________________________________ (Signature) _____________________________________ (Print Name) 1/2012 American LegalNet, Inc. www.FormsWorkFlow.com
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