I _______________________________________________________________________
(Print name of cardholder as shown on credit card)

Hereby authorize the Clarke Law Firm to charge my credit card:

CC #: _______________________________ __________ Expiration Date: ___________
(Must include 3 digit security code on back of credit card)

In the amount of US$ _________________________

In payment for legal related charges for:

_______________________________________________________________________
(Legal Services)

My billing address is:

Street Address:

_______________________________________________________________________________

City: ___________________________________ State: ________________ ZIP: ______________

Country: _________________________

Please note that a photocopy of the credit card (both sides) and driver's license or passport of the cardholder are required. Please fax them back attached to this form. (Copies must be legible).

Cardholder's Signature:

Date: _______________________________________________

Call for fax number