Online Payment Personal InformationFirst Name*Last Name*Company Name Address*City*State*Please select...AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyomingZip Code*Email Address*Telephone Number*Billing InformationSame as personal information: personal info and cardholder info is the sameCardholder's First Name*Cardholder's Last Name*Address*City*State*Please select...AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyomingZip Code*Payment InformationVISA MASTERCARD AMERICAN EXPRESS DISCOVERAmount to be charged to card* USD Card Number*Expiration date * 01 02 03 04 05 06 07 08 09 10 11 12 2021202220232024202520262027202820292030Responsible Attorney Invoice Number In consideration of HARRY D. POLATSEK, P.A. (POLATSEK, COUNSELLORS AT LAW), accepting payment for services by credit card rather than by cash or check, the undersigned does hereby waive and relinquish any rights the undersigned may have now or in the future to protest, dispute or refuse to pay the full amount charged on such credit card. This waiver specifically applies to any rights conferred by law or by the credit card companies to dispute an amount charged based on the quality of services that were/are going to be rendered. The undersigned acknowledges that any payment by credit card for past services rendered is an affirmation that such services were performed/rendered satisfactorily. The undersigned acknowledges that any payment by credit card for services to be rendered in the future is a non-refundable retainer. I agree to the terms and conditions above. If you would prefer to send your payment via Zelle, use this email in your bank’s interface: hpolatsek@polatsek.law