Credit Card Authorization Form

Organization Name*

Cardholder Name*

First NameLast Name

Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cardholder Email*

example@example.com

Cardholder Phone*

Please enter a valid phone number.

Communication Access Services*

On-site Sign Language Interpreting Product Image

On-site Sign Language InterpretingOn-site interpreting services have a 2 hour minimum. Please note, some assignments require more than 1 interpreter.

$130.00 Hours
Item subtotal:$0.00

Video Remote InterpretingVideo remote interpreting services have a 30-minute minimum. Please note, some assignments require more than 1 interpreter.

$3.35 Minutes

Live CaptioningLive captioning services have a 2 hour minimum.

$160.00 Hours

Total

$0.00

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

I hereby authorize Deaf Services Unlimited to charge my credit card upon the completion of services and confirm that the information for the credit card and billing address is complete and accurate.

Date*

Cardholder Signature*

Clear

Please verify that you are human*

Schedule an interpreter or captioner

Credit Card Authorization Form

Go ahead, expect too much.