Authorization To Bill
CREDIT or DEBIT Card

___________________________________________________________

Card Type ( check one only)   ____ Visa    ____ MC ____ Amex  _____ Disc.

Card No.  __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __

Security Code
(usually three to seven digits on signature line on back of card) __ __ __ __ - __ __ __

Name on Card ___________________________________________

Signature ____________________________________________

Phone: ____________________________ 

Address __________________________________________________________

City ________________________________  State ____ ____  Zip ___________

E-Mail Address:
(if you want YHIDC to E-Mail your receipts to you)

 _________@ ________________________________________________s

Payment Amount: $ ________________________. ________  

Frequency:   _______ One Time Only  _______Monthly    ________Yearly

Other Instructions: