The Law Offices of:

Scott C. Adams

Attorney at Law




To My Valued Friends & Clients: Many of you have asked, so I now take Credit Cards for services provided by my office.Because of the requirements imposed on how an attorney handles finances, there are some special conditions that must be met in order for me to be able to provide this convenience.Please fill in the following information (all blanks must be filled in), read the agreement, and sign where indicated.††††††††††††††††††††††††††††††††††† ††††††††††††††††††††††††††††††††††††††††††††††† Thank You!Scott


Credit Card Authorization Form For Services Received



Type of Card (Circle One):††††† ††††††††††††††††††††††††††††††† Visa††† /†††† MasterCard††† /†††† Discover


Card Number:†††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Expiration Date:††††††††††††††††††††††††††††††††††††††††††††


Verification Number (Usually 3-4 Digits in Signature Panel on Back of Card):†††††† †††††††††††


Name as it appears on Card:††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††


Billing Address of Card:†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††


City:††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† State:††††††††††††††††††††††††††††††††† Zip:††††††††††††††††††††††††††††††††††††††††


Your Telephone Number:†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††


Invoice Number to Pay:††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Amount: $†††††††††††††††††††††††††


I have received and reviewed the above Invoice Number and the Amount.I agree that I have received these services, am satisfied as to the services received, and I understand that this charge is non-refundable. I authorize this amount to be charged to this credit card:



Signature of Cardholder:(x)††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††


Please fill out this form and fax it to me at 503-324-1127 or mail it to me at my mailing address:

Law Offices of Scott C. Adams, Post Office Box 111, Banks, Oregon 97106-0111.


Sorry, by the Credit Card Companiesí rules, I canít take this Authorization by Email or over the Phone.