The Bobst International Center
160 East 53' Street, 1Ith Floor
New York, NY 10022

# Credit Card Payment Authorization

Office Facsimile
(212)639-4938
Office Telephone
212-639-4900

By signing below, I hereby authorize the Memorial Sloan-Kettering to charge my Credit Card for any physician visits, procedures, and tests, treatment modalities and/or services that may be provided to me at Memorial Sloan-Kettering Cancer Center.

We will require approval for each charge to the credit card.

Patient Account Number █████████
Patient Name (Last, First) ████████████████████
Payer Zip Code 10021
Payer E-Mail █████████████████
Relationship to Patient friend
Payment Amount <empty>
Indicate type of credit card to be charged (We do not accept Debit Cards)
[x] American Express
[ ] Mastercard
[ ] Visa
[ ] Diners Club
[ ] Discover
Credit Card Number ███████████████
Exp. Date ████████
CVN ████

<signature> CVN

Cardholder's Information: Me Address where the credit card statements are mailed)

Name ███████
Signature <empty>
Street 9 E 71st St.
City New York, NY
Country USA
PostalCode 10021
Telephone # ███████
Date 12/28/12

Credit Card Authorization may be faxed to The Bobs( International Center at (212)639-4938 Please call 212-6394900 to say you have faxed this font.

Payment Authorization Form Credit Card (revised 11/9/10)