As an authorized signer on the credit card listed below, I give Psychological Counseling Services, Ltd. permission to utilize this credit card for all charges related to and including services rendered at PCS.
Please specify the client(s) whose charges will be billed to this card:
16-digit card number. Your information is secure.
We do not accept American Express, or Discover Card.
Please format as 01/2017
3-digit security code
Additional Card required if FSA/HSA card
I hereby state that I authorize payment of charges to Psychological Counseling Services for the clients listed above. This credit card authorization has been signed electronically and my signature may not be identical to my written signature.