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Credit Card Authorization Form - Georgia
| Credit Card Authorization Form Form. This is a Georgia form and can be used in Middle District District Court Federal . |
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UNIT ED STAT ES DI STRI CT COURT M IDDL E DIS TRIC T OF GEO RG IA CREDIT CARD AUTHORIZATION FORM (Name of Company/Firm)hereby authorizes the United States District for the Middle District of Georgia to charge thecredit card listed below for payment of filing fees and other court related expenses incurred bythe individuals listed below. I certify that I am authorized to sign the form on behalf of my firm.Credit Cardholder Name:_________________________________________________________Address:______________________________________________________________________Telephone Number:________________________ Fax Number:__________________________Signature:______________________________________ Date:__________________________Card Type (Visa, MasterCard, Discover, American Express, Diners Club)__________________Card Number:_________________________________________________________________Expiration Date:___________________________ INDIVIDUALS AUTHORIZED TO USE ABOVE CREDIT CARD ACCOUNT ____________________________________ __________________________________________________________________ __________________________________________________________________ ______________________________Mail the original form to: CLERK, UNITED STATES DISTRICT COURT POST OFFICE BOX 128 MACON, GA 31202 This form will be stored in the courts vault for safekeeping purposes and will remain in effectuntil the cardholder specifically revokes it in writing. It is the responsibility of the cardholder and/or firm named above to submit a new formand notify the court when 1) authorized users change; 2) a credit card has been renewedresulting in a new expiration date; and 3) a card has been revoked, canceled or stolen.
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