NICKLES & ASSOCIATES LLC
PO BOX 1325
STEELVILLE, MO 65565
CREDIT CARD APPLICATION
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.
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)