Last updated: 5/8/2006
Authorization Form
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Description
United States District/Bankruptcy Court Western District of Missouri AUTHORIZATION FORM _________________________________________________________________ (Attorney Name/Firm) hereby authorizes the United States District/Bankruptcy Court for the Western District of Missouri to charge the following credit card number(s) for payment of identified Court-related expenses. PLEASE TYPE OR PRINT Visa Number________________________Exp. Date_____________ Mastercard Number___________________Exp. Date_____________ American Express ____________________Exp. Date_____________ Discover ____________________________Exp. Date ____________ Name____________________________________________________ Address__________________________________________________ City__________________________State_______Zip Code_________ Telephone Number__________________________________________ Authorized Signatures ____________________________ ___________________________ (Signed) (Typed) ____________________________ ___________________________ (Signed) (Typed) DATE ____________________ This form, which will be kept on file in the Clerks Office, shall remain in effect until specifically revoked in writing. It is the responsibility of the attorney/firm named herein to notify the Clerks Office, Finance Section of the new expiration date when a credit card has been renewed, or if a card has been canceled or revoked.
