Credit Card Authorization

Fields marked * are required. Prefer a PDF? The full form library is on the Client Portal.

Account Holder

Cardholder Name *

Date of Authorization

Law Firm

Phone *

Billing Email *

Cell Phone

Billing Address

Billing Street Address *

City

State

Zip Code

Card Information

Card Type *

Visa MasterCard Discover American Express

Card Number *

Expiration (MM/YY) *

CVV / Security Code *

Authorization Amount

Charge for individual services as authorized Keep on file for all future services

If kept on file, limit per authorization (enter an amount or "No limit")

Signature

By submitting, I authorize Le Process to charge my credit card for services rendered. I understand the card information will be kept on file until written notice of cancellation is received.

Type your full name as signature *

Date Signed

Security Notice

This form contains sensitive payment information. Submit it only over this secure connection. Do not send card numbers by unsecured email or text message.

Questions about billing? Call Khang Le at (832) 684-2472.