ACT-Payment Auth.pdf
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Atlanta Child Therapy - a Georgia-based 501c3 non-profit educational therapy corporation 2950 Cherokee Street, NW, Building 500, Kennesaw, Georgia 30144 Atlantachildtherapy.org – 678.895.5074 Payment Authorization Dear Client: In an effort to better serve you, Atlanta Child Therapy, Inc., accepts the following forms of payment: Cash, Check, Visa, and Master Card. If you wish to process your credit card through or office, please complete the form below. With your signature, you are authorizing Atlanta Child Therapy, Inc. permission to charge your credit card for the amount indicated below. We appreciate your business and hope this is a helpful service. Patricia M. Crawford, Ph.D. Credit Card Information Customer Name: Credit Card Type: Visa Master Card Credit Card Number: Expiration Date: CCV: Name as it appears on Credit Card: Payment Amount: Signature: Date: Credit Card Billing Address Street Address: City: State: Zip: Email:
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Transcript of ACT-Payment Auth.pdf
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Atlanta Child Therapy - a Georgia-based 501c3 non-profit educational therapy corporation
2950 Cherokee Street, NW, Building 500, Kennesaw, Georgia 30144 Atlantachildtherapy.org 678.895.5074
Payment Authorization
Dear Client: In an effort to better serve you, Atlanta Child Therapy, Inc., accepts the following forms of payment: Cash, Check, Visa, and Master Card. If you wish to process your credit card through or office, please complete the form below. With your signature, you are authorizing Atlanta Child Therapy, Inc. permission to charge your credit card for the amount indicated below. We appreciate your business and hope this is a helpful service. Patricia M. Crawford, Ph.D.
Credit Card Information
Customer Name:
Credit Card Type: Visa Master Card
Credit Card Number:
Expiration Date:
CCV:
Name as it appears on Credit Card:
Payment Amount:
Signature: Date:
Credit Card Billing Address
Street Address:
City: State: Zip:
Email:
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