NICKLES & ASSOCIATES LLC

PO BOX 1325

STEELVILLE, MO 65565

 

 

CREDIT CARD APPLICATION

 

Date: __________________

 

Name of Defendant: _______________________________

 

Name of Cardholder: ________________________________

 

Address Where Cardholder Gets Bill: ________________________ __________________________________________Zip Code: __________________

 

Subtotal Due (Bond Premium Paid) $_________________ (A)

Credit Card Fee (Premium X 5%)     $_________________ (B)

Total Charged to Credit Card (A+B) $_________________

 

Type of Credit Card (Circle One):    Visa      MasterCard     Discover

 

Credit Card Number: ___________________________________

 

Expiration Date: _________________ 3- Digit Security Code on Back: ___ ___ ___

 

I hereby authorize Nickles & Associates LLC to charge to my credit card the above total and any payments in arrears and I am the cardholder stated above. Proof of ID has been verified.

 

 

______________________________________                 ______________________

Signature of Cardholder                                                          Date

 

For pre-approval, please call the corresponding phone numbers.

MC/VISA:

DISCOVER:

 

Approval Code Number: ________________________ Agents Name: __________________________

 

AGENT- You must call the office within 48 hours with the approval code and return the original copy of this document with your weekly report to be paid.

 

_____ ARB (Automated Re Curing Billing)





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