SNYDER, GELBLUM AND SARID, CHARTERED

SGS CHARTERED

11447 CRONHILL DRIVE, SUITE L

OWINGS MILLS, MD 21117

(410) 581-3500

Credit Card Charge Authorization

NAME:               _________________________________________________________________________________________

                                                (FIRST)                                                                                     (LAST)

COMPANY NAME:  _____________________________________________________________________________________

ADDRESS (BILLING ADDRESS FOR YOUR CARD):     _____________________________________________________

ADDRESS (Line  2):      ___________________________________________________________________________________

CITY:        _________________________ STATE: ________________________ ZIP CODE__________________________

PHONE  (Work):  _______________________________________________________________________________________

PHONE (Home):   _______________________________________________________________________________________

TRANSACTION TYPE: Services rendered per invoice on the back.

CREDIT CARD TYPE (Circle one):    VISA     MC       

CREDIT CARD NUMBER: ______________-________________-_______________-________________________________

EXPIRATION DATE:    ______/______                    SECURITY CODE (three digits on the back of card):_______________

                                            MM  / YYYY

AMOUNT:            $_______________________________. ______

I AGREE TO PAY FOR THE SERVICES RENDERED IN THE AMOUNT SHOWN ABOVE ACCORDING TO MY CARD ISSUER AGREEMENT.

SIGNATURE:   _________________________________________