INVOICE OR RETAINER PAYMENT
Client Name:
Client/File No:  
Invoice Number:
Amount:
Cardholder Name:
Name: Phone: Email:
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By checking this box, the payor agrees that he/she is given authorization to use the credit card to be processed for payment of legal services and any associated expenses incurred by Polsinelli on behalf of the client. This agreement is for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to the account.
 
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Please direct any questions regarding this credit card payment and/or refunds to
Polsinelli Accounting or call 1-877-577-7455. Thank you.