Credit/Debit Card Authorization

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

CREDIT/DEBIT CARD INFORMATION

Card Type

Cardholder Full Name Card Number Expiration Date Billing Address City State Zip Code

AUTHORIZATION FORM

I, , authorize USPTO SOLUTIONS to charge my credit card ending in the last four digits above for agreed-upon purchases. I understand that my information will be saved to file for future transactions on my account.

Customer Signature

Date

This form authorizes charges related to Post-Filing Monitoring & Legal Follow-Up.