"Where we see the world through the eyes of children."™

CREDIT CARD INFORMATION AND AUTHORIZATION FORM

The Credit Card Rate is $180 per hour, plus any travel time or agreed upon additional expenses.  We will bill your credit card for each date of service and furnish you with either an email or fax confirmation.  No invoices will be sent for this payment method.  If your credit card is approved and then, for any reason, later payment is denied to us, there will be a $15 charge back fee.  (This is the fee that we are charged by our credit card company.)

Please print name as it appears on the card:  _________________________________________________

__ I wish to have an email confirmation.  Email address: _______________________________________

__ I wish to have a fax confirmation.        Fax number:   _______________________________________

I understand and agree to the above and wish to have services billed to my credit card unless I have paid Diane Provo directly in person.

Signature:_______________________________________________ Date signed:___________________

 Please mail completed form to
Provo & Associates, PO Box 357, Corte Madera, CA  94976-0357
or fax to 888-435-4016