Fee Arbitration Payment

Mandatory Fee Arbitration - Credit Card Authorization Form
(Form H)

PETITIONER'S INFORMATION

First Name

Middle Name

Last Name

RESPONDENT'S INFORMATION

First Name

Middle Name

Last Name

will be charged immediately

PAYMENT INFORMATION

Name on credit card

Billing Address Line 1

Billing Address Line 2

City

State

Zip Code

VisaMasterCardAmerican ExpressDiscover

Credit Card Number

Expiration Month

Expiration Year

CVV Code

I authorize the Beverly Hills Bar Association to charge my credit card the amount indicated above.