Authorization to Bill Credit Card for Legal Services
Mildred N. Phillips, Attorney at law
PO Box 453
Dedham, MA 02027-0453

Items in ORANGE are required.
Your Name (as it appears on card):
Phone Number:
Email Address:
Credit Card Type: Visa MasterCard Discover
Credit Card Number:   
Credit Card Expiration: (MM/YY)
Three-Digit Security Code (on back of card):     
Amount Authorized ($):     
Billing Address 1:     
Billing Address 2:     
City, State, Zip:     
Reason for Consultation:
By clicking the "Authorize/Submit"
button, I hereby authorize Attorney
Mildred N. Phillips to charge the amount
listed above to my credit card. I understand
that this is a one-time authorization and
must be completed each time that I wish
to make a payment.