Family Source Credit Card Authorization Form

Thank you for your interest in making your payment via a credit card to Family Source Consultants. Please complete the below Credit Card Authorization Form and our team will process your payment within 24 hours and send a confirmation of payment receipt to you.

Credit Card Authorization Form

Intended Parent First Name

Intended Parent Last Name

Purpose of Charge (i.e. Retainer, Match Payment, Final Payment, etc.)

Cardholder Information

Name on Credit or Debit Card

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Card Information

Credit Card Type

VISA

MasterCard

Discover

American Express

Credit Card Number

Expiration Date

CVV Code*

Cardholder Authorization

Type Your Name to Electronically Sign

Date Signed

*For Visa, MasterCard, and Discover, the CVV Code is the last 3 digit number located on the back of your card on or above your signature line. For American Express, it is the 4 digits on the FRONT of your card above the end of your card number.

By signing this form, I hereby authorize Family Source Consultants to charge my debit or credit card for approved transactions, and to keep the card on file to be used for future payments to outside businesses, with my approval. (May include, but not limited to: travel, monitoring clinic appointments, insurance payments, etc.) FSC will not charge or utilize the card without express permission from the cardholder. Note that prices for travel are subject to change at any moment – a prompt response when confirming booking will help to avoid price increases, though FSC is unable to guarantee prices will not fluctuate.

A 3% credit card service fee will apply.