Credit Card Information Card Type: MasterCard VISA Discover AMEX Other

Cardholder Name (as shown on card):

Card Number:

Expiration Date (mm/yy): CVV:

Cardholder Billing Address (include zip code): I, , authorize Augustine Counseling LLC to charge my credit card above for agreed upon charges. I understand that my information will be saved to file for future transactions on my account. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Augustine Counseling LLC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I acknowledge that the origination of Credit Card transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this Credit Card and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorization form.