Copy this page with your Driver's License and Credit as indicated below.
Fill out the form, sign it and either mail it to Roger Lampkin, 1234 L Street, Bakersfield, CA 93301 or fax it to (661)863-6741.
TO: Roger Lampkin
Please bill $________________ to my credit card as indicated below. The card number is
____________________________________ Expires _______/______. Verification code ______. The billing for the card comes to
(full address including zip)______________________________________________________________________________
The amount billed is to be used exclusively for (name of client) _________________________________________
If you have any difficulties with this transaction, you can telephone
me at (______)_________________ or (______)_________________
I hereby authorize Roger Lampkin to bill by credit
card as indicated above.