|
Credit Card
Authorization Form
Please complete
the following form and fax it to SRC
at 757-313-0892
or
mail to SRC, Inc. 125 St Pauls Blvd, Suite 310, Norfolk,
VA 23510
Please Print or Type
1.
Credit Card Type: Visa: □
MasterCard: □
American
Express: □
Discover:
□ Diners Club
International: □
2. Credit Card No. ____________________________ Security Code __________
(3 digits found on back)
3. Expiration Date: ______________
4.
Cardholder's name:
____________________________________________________________
5.
Cardholder's billing address:
_____________________________________________________
City:______________________ State: __________ Zip Code: _________
6.
Please indicate which services you would like to charge on this account
and the amounts:
Application Fee:
$75.00
□
Dossier Fee: ________________
□ (this varies for each country)
Home Study Fee _____________
□ (for Virginia families only)
Post- Placement Fee __________
□
(for Virginia families only)
Orphanage Donation __________
□
(please indicate which orphanage)___________
Family Research Package:
$500.00
□
Translation Services :
# Pages x $10
=
$
_______
□
Adoption Journal
($15.00 + 3.50 Shipping & Handling):
$18.50 □
Journal Sales Tax (for Virginia families
only) $
.68 □
Other: (please
specify)
___________________
□
7.
Daytime phone number: (_____)_______-____________
I
warrant that I am authorized cardholder for the credit card account
indicated above, and that funds are available to cover the costs
associated with the fees listed above.
Signature:
_____________________________ Date:
___________________________ |
Over
6 years experience & 300 completed intl. adoptions