| By signing this form, I authorize ClearScreening
to charge the specified card for compliance fees and
services rendered.
Name on Credit Card: ____________________________
Credit Card #: _____________________________
Credit Card CVV #: ___________ (AMEX-4 digit code on front above card #; ALL OTHERS-3 digit code on back after card #)
Credit Card Type: ____________________________
Credit Card Expiration Date: _____________________
Billing Address (if different than on application):
________________________________________________
________________________________________________
Credit Card Signature: ________________________________
Title: ______________________________
Date: ______________________________
[ ] Mark this box if you would also like to have
the $75.00 fee for on-site inspection applied to this
card (see #4 on previous page for more information).
Please also initial here to confirm your request for
an on-site inspection _____.
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