Automatic Payment By Credit Card Authorization Form    Please print out this Automatic Payment By Credit Card Authorization Form. Fax your completed form along with your Customer Profile, Subscriber Agreement, Nationwide Criminal Database Check (NCDC) Service Agreement Addendum if you require NCDC Reports, and  Motor Vehicle Subscription Agreement if you require access to MVR Reports to e-VERIFILE.COM at 770.859.0717. If you experience problems, please call Customer Support at 770.859.9899 Ext: 1.

	  Please check the type of card that you wish to authorize for transactions:

VISA __________  MasterCard __________

Bank Name or Credit Card: ________________________________________________

Bank Phone Number of Credit Card: _________________________________________

Credit Card #: ______________-_______________-______________-______________

Expiration Date on Credit Card: __________ / __________

Billing Address of Credit Card Holder:

_______________________________________________________________________

_______________________________________________________________________

Phone Number of Credit Card Holder: (__________) _________ - _________________

I authorize this information to be kept on file for future use. Yes ____   No ____

I authorize e-VERIFILE.COM, Inc. to charge my credit for purchases of their products
and / or services and to verify the billing address of my Credit Card with the issuing
bank upon my signature. If e-VERIFILE.COM, Inc. is unable to process my payment, 
I will be responsible for an alternate payment arrangement and any late fee which results.

By signing this authorization, I acknowledge that I have read and agree to all of
the above. All information given is complete and accurate.


Signature of Card Holder: __________________________________________________

Printed Name of Card Holder: _______________________________________________

Date of Signature: _________________________________________________________