First American Title Insurance Company AUTHORIZATION TO CHARGE CREDIT CARD ----------------------------------- Cardholder hereby authorizes the immediate charge to their credit card as set forth below. Upon receipt of the funds from the credit card company, the funds shall constitute the designated deposit required under the purchase agreement and said deposit shall be held by First American Title Insurance Company as escrow holder in accordance with the terms of the purchase agreement. Refund of the deposit amount will be subject to the terms of the purchase agreement. ________________________________________________________________________ Full Name (as it appears on the credit card) Credit Card Number:_____________________________________________________ (Type or print legibly) Expiration Date: _______________________________________________________ Zip Code of Cardmember: ________________________________________________ Amount of Charge Authorized: $__________________________________________ CARDMEMBER ACKNOWLEDGES RECEIPT OF GOODS AND/OR SERVICES IN THE AMOUNT OF THE TOTAL SHOWN HEREON AND AGREES TO PERFORM THE OBLIGATIONS SET FORTH BY THE CARDMEMBER'S AGREEMENT WITH THE CREDIT CARD ISSUER. ________________________________________________________________________ Signature of Cardmember ________________________________________________________________________ Printed Name of Cardmember ________________________________________________________________________ Date of Signature of Cardmember Please submit completed form to: Escrow Holder: 1160 N. Town Center Drive #190 Las Vegas, Nevada 89144 Attn: Transfer Dept Fax: 702-562-9760