*Company/Client Name/Seminar Name:

*Invoice Number(s)/Retainer:

(If seminar, indicate

name of seminar)

*Client/Matter Number:

(If you are remitting a retainer, please insert the word

RETAINER, attorneys name and amount of the retainer)

(If seminar, indicate

location of seminar)

Payment Information

*Card Number:

*Expiration Date:

(MMYY format)

* CVV2:

Billing Information

*Cardholder First Name:

*Cardholder Last Name:

*Billing Zip Code:

*Amount to Charge:

in US Dollars (US$)

*Contact Name:

*Contact Phone Number:

*Contact E-mail Address:

Comments:

see instructions below

If applicable, please specify what payment includes, such as name(s)
of seminar attendee(s) and/or any extras