Credit Card Authorization

Client Name*
First Last
Email*
Phone
Card Holder Name*
Card Number*
Expiration Month*
Expiration Year*
Security Code*
Address*
Street Address Address Line 2 City State ZIP Code
Consent*
I agree to the Privacy Policy.
I authorize Journey Assistance Counseling to bill my credit/debit card for the amount shown for services indicated below and/or for any ongoing balances on my account, including transaction service fees ($3 flat rate), until I terminate this authorization in writing. I also acknowledge that I am responsible for providing updated credit card information upon expiration or other change.
Signature*
Date*
MM slash DD slash YYYY