Free Credit Card Authorization Form - New Jersey

United States Bankruptcy Court for the District of New Jersey Credit Card Authorization Form
INSTRUCTIONS FOR COMPLETING FORM: This form can be obtained on our website at www.njb.uscourts.gov located under FORMS, followed by selecting Our Court's Misc. Forms. The form may be downloaded, completed and printed using the Adobe Acrobat Software. If you choose to complete your form by hand, please be sure to print legibly and use only blue or black ballpoint ink.

I hereby authorize the U.S. Bankruptcy Court for the District of New Jersey to charge the credit card listed below for payment of fees, costs and expenses which are incurred by the authorized user(s) listed below. I certify that I am authorized to sign this form on behalf of my law firm. I understand that this information will be securely maintained in the Clerk's office.

New Applicant Renewal Applicant If this is a renewal application, please provide your court issued internal identification number here: _________ Credit Cardholder Name: ____________________________________________________________________ Signature: ________________________________________ Date: _______________________

E:mail Address (if applicable): ________________________________________________________________ Law Firm Name: ___________________________________________________________________________
(If sole practitioner, type in your name)

Address: ________________________________________________________________ ________________________________________________________________ Telephone Number: ________________________ Fax Number: ______________________

NAMES OF INDIVIDUALS AUTHORIZED TO USE ACCOUNT NUMBER LISTED BELOW: (Include cardholder name, if authorized user. Please use a separate sheet of paper for additional names)

Name ____________________________ ____________________________ ____________________________

BAR I.D. ______________ ______________ ______________

E:mail Address (if applicable) ________________________________ ________________________________ ________________________________

Credit Card Account Number (do not include hyphens) If you are using Discover, MasterCard or Visa you must provide the 3-digits CVV2 (Customer Verification Value) in back of card.

If you are using American Express you must provide the 4-digits CID (Confidential Identifier Number) in front of card.

Expiration Date (MM/YY): CARD TYPE (Please check only one): American Express Discover MasterCard VISA

This form will be kept on file in the Clerk's Office and will remain in effect until the expiration of the credit card account. Applicants may also revoke this form by submitting a written request to the address listed below. A new application must be submitted each time there is a change of any information that you have provided within this document. Please notify the court immediately if the credit card on file is lost or stolen.

Mail this application to the attention of Lisa M. Dash located at: United States Bankruptcy Court, P.O. BOX 1352, Newark, NJ 07101-1352
FOR COURT USE ONLY Recv'd __________ Completed by ________

Memo:_______________________________________________________________________

Accepted

Declined

O:\Analyst\CREDIT\2004USBCDNJ.CCA.wpd (Rev.9/2004)