Globe Language Services, Inc. Tel: (212) 227-1994

305 Broadway 4^th Fl. Fax: (212) 693-1489

New York, NY 10007-1187 www.globelanguage.com

PRE-AUTHORIZED CHARGE FORM

I authorize Globe Language Services, Inc. to keep my signature on file and to charge my credit card listed below for:

The one-time amount of $__ will be billed to:

(No third party credit cards)

Customer Name:

Cardholder Name:

Credit Card Billing Address:

Visa

MasterCard

Discover

American Express

Account Number:

Expiration Date: (month/year):

Credit Card Code:

(3 Numbers located on the back of the card with signature or the 4 numbers in the front of an American Express card)

If you want this translation or evaluation to be mailed to an agency or another person, please provide name and address below.

SIGNATURE: ________ DATE: __________