Credit Card Payment Authorization Credit Card: Visa Mastercard Discover. AMEX 4 ) je Expiration Date: > Security Code: d | am, (ee = 3 Name as it appears on credit card: _ ) GE R= — = Billing Address for card: FG EAST H Sh NN ALY jooa4 “PAYING Poe ABB cc enna TAN. 13,508 the above named account h authorize $ to be charged monthly to my credit card on th business day of each month for orthodentic services rendered in accordance with ‘ontract with MJR Dental Services LLC. The first charge-wi ereby acknowledge that the every month until my account is pai if the payment is declined for any reason, a $39.00 fee will b mptly remit the total monthly payment due. If of the month, a $50.00 late fee will Jeffrey Rappapo'! Date: An ic: Daw Signature of account holder: ———— EFTA00313919