Document ID: f3f2f9789296e78314b1496be604a26c2d5ad7ca
January 3, 2018
Signed On : https://www.cirquelodge.com/Forms

Credit Card Authorization Form - Julia Himberg


This form has been created in order for expenses to be charged to your credit card including pharmacy charges. Please provide all the information requested below to ensure prompt processing of your application. We ask you to please send admissions a photo/copy of your credit card. Please sign and date the form before submission and email or fax additional information to Cirque Lodge at (801) 222-0112.

Resident Information

Name: Amy Himberg Gender: Female

Phone Number: 385-448-7844 SSN: Birth Date: 11/25/1982

Address: 341 N 1100 East

City: American Fork State: UT Zip Code: 84003

 

Card Holder Information

Name: Julia Himberg

Phone Number: 2408885081

Address: 6815 S. McClintock Dr. #2241

City: Tempe State: AZ Zip Code: 85283

 

   

Relationship to Cardholder: Sister

Credit Card Information

Please fill out credit card information below and specify the purpose of use for the card (i.e., treatment, incidental charges, pharmacy charges, etc.) Additional lines are provided if you would like to use separate cards for different purposes.

Credit Card#: Name on Card: Card Type: Exp Date: Sec. Code: Purpose for Card
4815831016469806 Julia Himberg Visa 03/21 313 Cirque final payment

I certify that I am the listed cardholder and that all information is complete and accurate. I hereby authorize Cirque Lodge, and any third party entities associated with Cirque Lodge (such as Harmon’s Pharmacy) to collect payment on all charges incurred by the above referenced resident which are not covered by insurance by processing a charge to the credit card listed above. I agree and guarantee to pay in full any indebtedness, obligation and/or liabilities owing to Cirque Lodge and/or its agents by the above referenced resident, including, but not limited to treatment cost, medical copayments, copayments and/or self-payments for medication, supplies, lab tests, shipping costs, therapeutic books, phone cards, salon and massage services, dry cleaning, Cirque apparel, fishing licenses, outpatient counseling sessions and/or miscellaneous charges including finance charges or collection fees.

Signed by Julia Himberg
Signed on:January 3, 2018

Signature Certificate
Document name: Credit Card Authorization Form - Julia Himberg
Unique Document ID: f3f2f9789296e78314b1496be604a26c2d5ad7ca
Julia Himberg
Party ID: 2505b325-41f9-4b14-8ba9-f58cb292a3ab
IP Address: 70.171.254.87
Security Level: E-mail
Digital Signature:
Multi-Factor
Digital Fingerprint Checksum
2f5b3dc24147fb8be914c047bb9eeba7
Timestamp Audit
January 3, 2018 11:09 am MSTCredit Card Authorization Form Uploaded by Courtney McShay Carroll - information@cirquelodge.com IP 205.204.44.102
January 3, 2018 11:09 am MSTDocument sent for signature to Julia Himberg - julia.himberg@gmail.com
January 3, 2018 11:30 am MSTDocument signed by Julia Himberg - julia.himberg@gmail.com IP 70.171.254.87
January 3, 2018 11:30 am MSTThe document has been signed by all parties and is now closed.