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Credit Card Collection Network Authorization Form - Washington
| Credit Card Collection Network Authorization Form Form. This is a Washington form and can be used in USDC Eastern Federal . |
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UNITED STATES DISTRICT COURT EASTERN DISTRICT OF WASHINGTON CREDIT CARD COLLECTION NETWORK AUTHORIZATION FORMWe/I hereby authorize the United States District Court for the Eastern District of Washington to chargethe following bank card number(s) for payment of filing fees and other court related expenses:Name as it appears on Card:____________________________________________________________Name of Firm/Company:_______________________________________________________________Name of other authorized users:_________________________________________________________ __________________________________________________________ __________________________________________________________Cardholders Mailing Address:__________________________________________________________City:__________________________________ State:____________ Zip:________________________Business Mailing Address:_____________________________________________________________City:____________________________________ State:__________ Zip:________________________Business Phone No._____________________________ Fax No.:______________________________Master Card No.____________________________________Exp.Date:________________________Visa Card No.______________________________________ Exp. Date:_______________________Discover Card No.___________________________________ Exp. Date:_______________________American Express:___________________________________ Exp. Date:_______________________Diners Club No.:____________________________________ Exp. Date:_______________________Please indicate if this information is [ ] NEW [ ] UPDATEDThis form will be kept on file in the Clerks Office and shall remain in effect until specifically revoked inwriting. It is the responsibility of the firm/company named herein to notify the Clerks Office of the newexpiration date when a credit card has been renewed or if a card has been canceled or revoked.Signature:___________________________________________Date:___________________In the event the charge against this account is denied, you will be notified immediately to make payment in cash,money order or certified check. Any abuse of this privilege may result in your removal from the credit card program.**PLEASE RETURN COMPLETED FORM TO TH E FINANCIAL DEPARTMENT, U.S. DISTRICTCOURT, EDWA, 920 W. RIVERSIDE, ROOM 840, PO BOX 1493, SPOKANE, WA 99210.
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