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.

FROM:     _______________________________________________

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 (______)_________________

Put your Driver's License or ID Card here
Put your credit card here

I hereby authorize Roger Lampkin to bill by credit card as indicated above.

                                                            Signature  ___________________________________