Credit Card Payment Authorization

Automated Office Systems

PO Box 9004

Lynbrook, NY 11563-9004

Please fax this form to:

Fax # 516-396-5585

Please fill out the information below as it appears on your credit card. Please sign and date the bottom of this form. AOS will automatically charge your card each month.

CARD NUMBER: ________________________________________________

EXP DATE: ______/_______ Security code # ________

CARDHOLDER’S

NAME: ____________________________________________________

Address: ________________________________________________

City: ____________________State: ________ Zip:___________

AOS BILL CODE :(_________________) as it appears on your AOS bill in bold type

AMT: $_________________

Doctor’s Office Phone # (_______)__________________

______________________________________________________________________________

By signing below, I authorize Automated Office Systems, (AOS) to charge the above credit card in the amount indicated above. I understand that by signing this document, I agree that this transaction shall be handled as a cash transaction and my recourse via the credit card company is hereby waived.

Cardholder’s Signature: ____________________________________ Date:_______________

***Please Fax or Send this form to Automated Office Systems (AOS) Fax# 516-396-5585***

Send To: Automated Office Systems, PO Box 9004, Lynbrook, NY 11563-9004