Credit Card Authorization Form

Please complete all fields.

Credit Card Information

Card Type: ☐ MasterCard ☐ VISA ☐ Discover ☐ AMEX

□ Other

Cardholder Name (as shown on card):

Card Number:

Expiration Date (mm/yyyy):

Cardholder ZIP Code (from credit card billing address):

_______________________________________________________________________________.

I, _____________________________________, authorize PHILLIP L. WEINBERG, Attorney at

Law, to charge my credit or debit card described above for agreed-upon purchases of his flat-
fee legal services and/or costs per the separate contractual agreement(s) entered into with him.
I understand that my information will be not be saved for any future transactions on my account,
other than the last 4 digits of my cards number. This authorization is for legal services to be
provided to: _________________________________________________________.

I further unconditionally and bindingly agree not to request, order, undertake or cause
to undertake a chargeback for any reason, and that if I or the actual client have a dispute
with Attorney Weinberg I/they will resolve it in another manner, such as directly with him, or
through the bar association, or via fee arbitration or court action.

I also agree to provide Attorney Weinberg within 24 hours from the payment with a legible color copy
or scan of the front and back of every card used to pay his fees for this matter.

Payor Signature Date

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