Credit Card Payment Form

Authorization to Bill Credit Card for Legal Services Mildred N. Phillips, Attorney at law 6 Beacon Street, Suite 800 Boston, MA 02108 Items in RED are required.
Your Name (as it appears on card):
Phone Number:
Email Address:
Credit Card Type:	Visa MasterCard Discover
Credit Card Number:
Credit Card Expiration: (MM/YY)
Three-Digit Security Code (on back of card):
Amount Authorized ($):
Billing Address 1:
Billing Address 2:
City, State, Zip:
Reason for Consultation:
By clicking the "Authorize/Submit" button, I hereby authorize Attorney Mildred N. Phillips to charge the amount listed above to my credit card. I understand that this is a one-time authorization and must be completed each time that I wish to make a payment.	<