Credit Card Authorization Form
By completing this form, you authorize COUNSELING CENTER OF MONTGOMERY COUNTY to keep your signature on file and to charge your credit card for services. Please note, if you are paying for court related services or case management fees and should the services rendered exceed the initial charge then CCMC will process another charge to resolve the outstanding balance and cover the additional time for the provider or staff with your case. Please complete and submit the form if you agree.
Email address *
Date *
MM
/
DD
/
YYYY
Enter the name on the Credit Card *
Your answer
Client name (person receiving service) *
Your answer
Relationship to client: *
Service you are paying for *
Required
Credit Card billing address (Street address, City, State, Zip) *
Your answer
Credit Card *
Credit Card Number
Your answer
Expiration date: *
Your answer
Security Code: *
Your answer
Enter amount owed: (subject to 3.5% surcharge) *
Your answer
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This form was created inside of Counseling Center of Montgomery County.