This form provides authorization information to The Osborne CPA Firm, P.C. allowing them to validate signature authority on various transactions. This form should be completed annually with the beginning of each state fiscal year. This form should be updated any time there is a change. Please fill out and fax this form to (770) 437-4025:
Company Name: _________________________________________________
Contact Name: __________________________________________________
Mailing Address: _________________________________________________
Telephone Number: __________________ Fax Number: _________________
Email Address: __________________________________________________
Name as it appears on Credit Card: __________________________________
Card Type (Please Circle One): Visa Mastercard American Express
Card Number: ___________________________________________________
Exp. Date (MM/YY): ___________ Security Code (3 or 4 Digits): ____________
Cardholder Signature/Charge Authorization: ___________________________
Notice: Your credit card will be billed for retainer required and/or upon
completion of services provided by The Osborne CPA Firm, P.C.
