Credit Card Payment Authorization


Automated Office Systems

PO Box 9004

Lynbrook, NY 11563-9004


Please fax this form to:

Fax # 516-396-5585


Please fill out the information below as it appears on your credit card. Please sign and date the bottom of this form. AOS will automatically charge your card each month. 


CARD NUMBER:                  ________________________________________________



EXP DATE:                            ______/_______   Security code # ________




NAME:           ____________________________________________________


Address:         ________________________________________________


City:                ____________________State: ________ Zip:___________


AOS BILL CODE :(_________________) as it appears on your AOS bill in bold type


AMT:              $_________________


Doctor’s Office Phone # (_______)__________________




By signing below, I authorize Automated Office Systems, (AOS) to charge the above credit card in the amount indicated above. I understand that by signing this document, I agree that this transaction shall be handled as a cash transaction and my recourse via the credit card company is hereby waived.   


Cardholder’s Signature: ____________________________________  Date:_______________


***Please Fax or Send this form to Automated Office Systems (AOS) Fax# 516-396-5585***

Send To: Automated Office Systems, PO Box  9004, Lynbrook, NY 11563-9004